Name of Manual - Blue Cross and Blue Shield of Minnesota

Urgent/Expedited
Appeals
Appeals
An urgent appeal is done when an initial or continued treatment is
dependent on a quick determination. Urgent is defined as medical
care or treatment with respect to which the application of the time
periods for making nonurgent care determinations:
1. Could seriously jeopardize the life or health of the claimant or
the ability of the claimant to regain maximum function,
although it may not rise to the level of being a life-threatening
circumstance, or
2. In the opinion of a physician with knowledge of the claimant’s
medical condition, would subject the claimant to severe pain
that cannot be adequately managed without the care or
treatment that is the subject of the claim.
Urgent appeals are completed within 72 hours of receipt of the
appeal request, or sooner, based on the medical exigencies of the
case. Providers should contact the Blue Cross clinician who signed
the denial letter to initiate an urgent appeal.
Coding Appeals Blue Cross’ coding edits are updated at minimum annually to
incorporate new codes, code definition changes and edit rule
changes. All claims submitted after the implementation date of this
update, regardless of service date, will be processed according to
the updated version. Where Medicare’s CCI (Correct Coding
Initiative) edits are identical, we will consider the appeal with
additional documentation; however, the issue is likely to be
upheld. Adjustments, and/or request refunds will not be made
when processing changes are a result of new code editing rules due
to a software version update. Notice of this update will be
published in the Provider Press and/or a Provider Bulletin.
Blue Cross has adopted a standard process to review coding edit
appeals and providers have the right to appeal with additional
information. Appeals received without additional information will
not be reviewed. The denial will be upheld.
If you have a question or appeal about our policy regarding a
particular coding combination, provide a written statement of the
concern, along with the following and/or documentation normally
required for a medical review.
Written explanation supporting the procedures submitted, i.e.,
specific references, specialty specific criteria
Documentation from a recognized authoritative source that
supports your position on the procedure codes submitted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-5