What is the process for appealing a denied claim?

The process for appealing a denied claim can vary depending on the specific policy and the Blue Cross Blue Shield Plan you are working with, but there are general steps that typically apply. Initially, it is important for the member to carefully review the explanation of benefits, or EOB, that outlines the reason for the denial. This document will provide crucial information regarding what specific aspects of the claim were not approved and will help identify potential grounds for an appeal. Once the member has reviewed the EOB, the next step is to gather any supporting documentation or information that may bolster the appeal. This could include medical records, additional bills, or statements from healthcare providers, demonstrating that the service or treatment was necessary and appropriate according to the member's health care needs. The member should then prepare a formal appeal letter addressed to the appropriate Blue Cross Blue Shield department, citing the claim number and including all relevant details. In this letter, it is helpful to clearly state the reasons for the appeal, referencing any supporting documents included. After the appeal letter is submitted, the Blue Cross Blue Shield Plan typically has a set timeframe to respond, which is often within 30 to 60 days. During this time, the plan may conduct a further review of the claim and any accompanying documentation. It is recommended for members to monitor their progress by keeping records of all correspondence and communication related to the appeal. If the appeal is denied once again, members have the right to request a second level review or to seek external review, depending on the specific guidelines of their plan. For precise procedures and timeframes, members are encouraged to refer to their policy documents or visit the official Blue Cross Blue Shield website for additional information and guidance regarding claims and appeal processes.