Name of Manual - Blue Cross and Blue Shield of Minnesota

Appeals of Processed
Claims
Voluntary Second
Appeal
Situations brought to appeal include the following categories:
Benefit determinations
Claims processing
Determinations of allowed amounts
Provider profiles
Timely filing denials
Services denied due to lack of medical necessity
Appeals
This appeal process does not apply to settlement appeals, medical
necessity and prior authorization denials occurring prior to claim
submission.
Voluntary Second Appeals must be filed within 60 days of the
notification upholding the decision of the initial appeal. To be
eligible for a voluntary second appeal, the amount at issue must be
$500.00 or more. Calculate the amount at issue by subtracting the
deductible, coinsurance, and paid amount from the billed charge.
For example:
Billed amount $2,000.00
- (deductible) 500.00
- (coinsurance) 200.00
- (paid amount) 500.00
Amount at issue $ 800.00
If the amount in question is $500.00 or more then this appeal
review may be conducted by the Consumer Service Center as well
as Integrated Health Management.
Claims for the same patient or multiple patients relating to the
same category can be aggregated at this level (you may combine
two or more claims to meet the $500.00 amount-in-controversy
requirement).
Voluntary second appeals must be submitted with additional
information over and above what was submitted with the initial
appeal. These requests must also be submitted on an AUC Appeal
form and should note “Secondary Appeal” on the form.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-3