There may be times when you disagree with how we’ve processed a claim for one of your patients. Perhaps you disagree with:

• How we applied coding and payment rules
• Our interpretation of the terms of the member’s benefit plan, such as the definition of medical necessity
• Our decision regarding provider versus member financial responsibilities

We encourage you to contact Provider Services any time you have questions about how a claim was processed. In some cases, we may be able to resolve the issue simply by clarifying how the decision was made. There may be instances, however, when you want to formally request a provider reconsideration to investigate the outcome of a finalized claim.

Submitting a Reconsideration Request

Local South Carolina Requests

Participating physicians and other health care professionals located in South Carolina must submit reconsideration requests in writing. Your request should include the following information for a one-time review of a locally processed claim:

• Provider Reconsideration Form, completed in its entirety
• An explanation of the issue(s) you’d like us to reconsider
• Any supporting documentation, such as:
  • The patient’s health history for denials related to medical necessity or investigational 
  • Operative reports, office notes, pathology reports, hospital progress notes, radiology reports or lab reports

Send the form and supporting materials to the appropriate fax number or address noted on the form. Do not use this form when submitting an appeal on behalf of the member.

BlueCard^® Requests

South Carolina providers requesting a review of a BlueCard claim (the member belongs to another Blue^® plan) should include the following information:

• BlueCard Claim Appeal Form, completed in its entirety
• An explanation of the issue(s) you’d like us to reconsider
• Any supporting documentation, such as:
  • The patient’s health history for denials related to medical necessity or investigational 
  • Operative reports, office notes, pathology reports, hospital progress notes, radiology reports or lab reports

Send the form and supporting materials to the fax number or address noted on the denial notice. Do not use this form when submitting an appeal on behalf of the member.