Resources

Blue Cross and Blue Shield of Alabama has an established appeals process for providers and physicians. The following documentation provides guidance regarding the process for appeals. Three forms are also available to aid providers in preparing an appeal request. Please make sure you select the appropriate form to address your specific need.

• PRO-80 — Claims Reconsideration Form: To be used for review of coordination of benefits (COB), coinsurance/deductibles, coverage/benefits, eligibility and/or timely filing
• PRO-81 — Professional Reimbursement Appeal Form: To be used for payer allowance and/or incorrect payment or coding rules applied
• PRO-82 — Utilization Management Appeal Form: To be used for medical necessity appeals (including cosmetic and investigational). Blue Advantage^® is excluded.

For more information about the appeals process, see the following:

• Post-Service Q & A
• PreService Q & A

Providers are required to file all post-service appeals to their local Blue Cross Plan regardless of the member's Home Plan. For example, if an Alabama physician provides services to a member with Blue Cross and Blue Shield of Kansas coverage and a post-service appeal is needed, the physician should fill out the appropriate form from above and submit it to Blue Cross and Blue Shield of Alabama.

Please attach any additional information and/or medical records at the time of filing the appeal for consideration.

Preservice and concurrent appeals should continue to be submitted to the member's Home Plan.