Why file an appeal?
As a Blue Cross Blue Shield of North Carolina (Blue Cross NC) member, you have the option to file an appeal when a claim is denied. You may choose to file an appeal to dispute a payment or coverage decision or for other adverse benefit determinations.
An adverse benefit determination means your health insurance plan has denied a benefit, won’t pay for a service you’ve already gotten, or has rescinded coverage.
You don't have to figure it out alone. Blue Cross NC is here to help every step of the way when it comes to how to file an appeal.
When to file an appeal
You might want to appeal if your claim was denied for any of the following reasons:
- Your plan doesn't cover services or procedures listed on the claim.
- The procedures received are considered not medically necessary, experimental, investigational, or cosmetic.
- The coverage requires pre-authorization.
- Your claim was denied due to a benefit limit.
You can learn more about insurance claims by visiting our blog article on the topic.
When you make an appeal, Blue Cross NC will review your case to determine whether the services you received are covered by your plan.
How to file an appeal
As a Blue Cross NC member, use the member appeal form (PDF) to dispute a payment or coverage decision or to appeal other adverse benefit determinations. This process applies to our individual and family (under age 65) members.
To get started on filing an appeal:
- Review the appeal instructions in your explanation of benefits (EOB) or in your adverse benefit determination letter. You can find your EOBs in your Blue Connect account.
- Gather necessary information, such as medical history and records, referrals, or additional facts.
- Keep records of all claim documents and phone conversations, including dates, times and notes taken.
- To appoint an authorized representative to help with your appeal, complete the Member Appeal Representation Authorization Form (PDF).
- Submit the proper appeals form(s) from the list below:
Where to send your appeal forms
Appeals requests can be submitted by US mail to our appeals address:
Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 30055
Durham, NC 27702-3055
For dental appeals, please follow the instructions in the dental appeals and grievances forms:
Appeals FAQ
You must submit your appeal within 180 days of the date on the adverse benefit determination notice.
Depending on your plan or the level of review, the timeline for deciding on your appeal may vary. Contact us, and a Blue Cross and Blue Shield of North Carolina customer service representative can help you determine how long the process might take, or check your benefit booklet for appeal timeframes.
To appeal a claim, fill out the member appeal form (PDF). If you prefer to write a letter of appeal, make sure you include:
- Your name
- Your subscriber ID or member ID number (found on your member ID card)
- Service / claim information
- Reason for the appeal
- Any comments, supporting documents, records and other information you'd like us to consider
There are two ways to submit an appeal:
- By mail:
Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 30055, Durham, NC 27702-3055
- By fax:
Fax: 919-765-4409 (or 919-765-2322 for State Health Plan PPO plan)
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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