Claim Review and Appeal

Requesting a Claim Review

After adjudication, additional evaluation may be necessary (such as place of treatment, procedure/revenue code changes, or out-of-area claim processing issues).

  • Electronic claim reconsideration requests are available for review and/or reevaluation of situational finalized claim denials online (including BlueCard® out-of-area claims). This method of inquiry submission is preferred over faxed/mailed claim disputes, as it allows you to upload supporting documentation and monitor the status via Availity® Essential. For more details, refer to the Claim Reconsideration Requests page  and instructional user guide in the Provider Tools section of our website.
  • To request a review by mail, complete the Claim Review Form. Follow instructions on the form and mail to the address indicated.

Non-Participating Providers

Claims for certain services may be eligible for payment review under the No Surprises Act (NSA) if you don’t have a contract with us. Log on to Availity Essentials to request a claim review and initiate a negotiation for NSA-eligible services. See our user guide for more details.

Appeals

A provider appeal is an official request for reconsideration of a previous denial issued by the Blue Cross and Blue Shield of Montana (BCBSMT) Medical Management area. This is different from the request for claim review request process outlined above. Most provider appeal requests are related to a length of stay or treatment setting denial.

  • Appeals may be initiated in writing or by telephone, upon receipt of a denial letter and instructions from BCBSMT. Please note that some groups may require appeals to be submitted in writing.
  • A routing form, along with relevant claim information and any supporting medical or clinical documentation must be included with the appeal request.
  • The physician/clinical peer review process takes 30 days and concludes with written notification of appeal determination.

A member appeal may be submitted by the member or their authorized representative, physician, facility or other health care practitioner.

Written authorization from the member is required with the exception of urgent care appeals. Urgent care appeals can be faxed to 406-441-5569. Brief descriptions of the various member appeal categories are listed below.

  • A clinical appeal is a request to change an adverse determination for care or services that were denied on the basis of lack of medical necessity, or when services are determined to be experimental, investigational, or unproven. May be pre- or post-service. Review is conducted by a physician. Electronic clinical appeal requests for specific clinical claim denials may be submitted via Availity. When applicable, the Dispute Claim option is available after completing an Availity Claim Status request. See the Electronic Clinical Claim Appeal Request page in our Provider Tools section of our website for more information.
  • A non-clinical appeal is a request to reconsider a previous inquiry, complaint or action by BCBSMT that has not been resolved to the member's satisfaction. Relates to administrative health care services such as membership, access, claim payment, etc. May be pre-service or post-service. Review is conducted by a non-medical appeal committee.
  • Urgent care or expedited appeals may be requested if the member, authorized representative or provider feels that non-approval of the requested service may seriously jeopardize the member's health. The provider or facility may request an expedited appeal by calling the number on the back of the member's ID card.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.