Name of Manual - Blue Cross and Blue Shield of Minnesota

Supporting
Documentation
Appeals
The two key elements for submitting documentation with appeal
requests are the patient’s name and the date of service. Both should
be included on each page of the documentation submitted.
Additionally, the documentation should correspond with the dates
of service at issue.
When the provider submits the appealed claim, the responsibility
for gathering and submitting documentation that supports the
service rests with the provider. We will offer guidance and
assistance as necessary, but the responsibility for identifying what
is needed and where it is located is yours.
The list below includes common types of claim denials/reductions
that may be submitted for appeal and the sources of documentation
suggested for each type. This information is presented as a guide to
assist you and is not a complete listing.
Type of Denial or
Reduction Documentation
Surgical
Complications
Operative report, chart notes, letter
stating rationale for complication
Medical Necessity Medical records and rationale for service
performed
Investigative Medical records and rationale for service
performed
Cosmetic Medical records and rationale for services
DRG/Category Code Rationale for questioning of payment
Private Room Notes, doctor’s order and letter of
medical necessity
Allowed Amount for
unlisted codes
Allowed Amount – for
modified CPT/HCPCS
codes.
Allowed Amount –
excluding unlisted
codes.
Chart notes or invoice, NDC number and
a letter to review allowance for an
unlisted code. This is independent from
medical necessity review process.
Note: An invoice is required for DME
or supply allowance appeals.
Chart notes, letter and operative report
when applicable to review allowance.
Copy of fee schedule or provider
agreement.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-7