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Sunday, June 6, 2010

Documents required for appeal.

Examples of Grievances

Grievances processed by the Claims Dept.

• COB issues
• Coinsurance/deductible and sanction deductible
• Fee schedule disputes
• Timely filing

Grievances processed by the Medical Appeals and Grievances Dept.
• ASC pricing and global fee pricing
• DRG payment
• Fragmentation of incidental procedures
• Modifiers
• Multiple medical/surgical procedure processing
• Mutually exclusive procedures
• Procedure unbundling
• Investigational (member not responsible)
• Not medically necessary (member not responsible)

Documentation Required

• Detailed explanation of issue or correction
• BCBSAZ claim number
• Copy of corrected claim, if applicable
• Evidence of primary payer reimbursement (for COB issues)
• Supporting documentation

Proof of claims filing and timeliness

Paper claim: A copy of the computer screen-print showing date of submission to BCBSAZ.
Electronic claim: A copy of the APN report showing receipt of the clean claim by BCBSAZ.
For both claim types: Include dates of timely follow-up with BCBSAZ and the BCBSAZ contact name.

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