Provider Reconsiderations

There may be times when you disagree with how a claim for one of your patients was processed. This may involve our application of coding or payment rules, interpretation of the member’s benefit plan (including medical necessity), or determination of provider versus member financial responsibility.

We encourage you to contact Provider Services whenever you have questions about a claim. In many cases, concerns can be resolved through clarification. If additional review is needed, you may submit a provider reconsideration to request a formal review of a finalized claim.

Submitting a Reconsideration Request

Local South Carolina Requests

Participating physicians and other health care professionals located in South Carolina must submit reconsideration requests in writing. Your request should include the following information for a one-time review of a locally processed claim:

• Provider Reconsideration Form, completed in its entirety
• An explanation of the issue(s) you’d like us to reconsider
• Any supporting documentation, such as:
  • The patient’s health history for denials related to medical necessity or investigational 
  • Operative reports, office notes, pathology reports, hospital progress notes, radiology reports or lab reports

BlueCard^® Requests

South Carolina providers requesting a review of a BlueCard claim (the member belongs to another Blue^® plan) should include the following information:

• BlueCard Claim Appeal Form, completed in its entirety
• An explanation of the issue(s) you’d like us to reconsider
• Any supporting documentation, such as:
  • The patient’s health history for denials related to medical necessity or investigational 
  • Operative reports, office notes, pathology reports, hospital progress notes, radiology reports or lab reports

Note: For both, send the form and supporting materials to the appropriate fax number or address noted on the form. Do not use these forms when submitting an appeal on behalf of the member.