Appeal and Grievances

Provider Dispute Process

Members and providers acting on a member’s behalf have the right to appeal how a claim was paid or how a utilization management decision was made. If you are dissatisfied with the Plan’s payment of the claims listed herein, you have the right to file a complaint with the Plan.

Appeals regarding a denial of coverage based on dental necessity must be submitted in accordance with the appeals procedure, timeframe and address printed on the member’s Explanation of Benefits (EOB) unless otherwise prescribed by state regulations.

An appeal must include:

Member name
Claim ID
Nature of the appeal including identification of the service
Appropriate supporting documentation (such as X-rays or periodontal charting) and a narrative stating why the service should be covered.

Appeal rights vary by business and/or state. Refer to the appeals language on the back of the Provider Remittance Advice (PRA)/ Electronic Remittance Advice (ERA) for guidance with the appeals processes that are appropriate for each particular claim.

There are two types of provider appeals:

Utilization Management (UM) Appeal: Any appeal that is based on dental necessity and/or would require review by a dental clinician. UM appeals must include a narrative and any supporting documentation including X-rays.
Administrative Appeal: Appeals that are not based on dental necessity. This type of appeal would include but is not limited to appeals for timely filing of claims, member’s eligibility, over/underpayment adjustment requests, etc. Administrative appeals must include a narrative.

Resources

Appointment of Representative Form

Blue Shield of California Appointment of Representative Form

California Grievance Form

Member Authorization Form

Start an Appeal