Highmark bcbs appeal address

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You must request for your services to continue by 10 days from the date this notice is mailed, or the date services will change. You can make this request by phone. Call us at if you think this form will not reach us by mail before the deadline. If you feel your health will be seriously harmed by waiting for a decision on your health plan appeal, you or your doctor can ask for an emergency health plan appeal.

If you qualify for an emergency health plan appeal, we must decide to approve or deny your appeal within 72 hours of your request. If your appeal is denied, you have the right to ask for either a non-emergency or emergency State Fair Hearing or External Medical Review.

To ask for a State Fair Hearing, you or your representative should either send a letter to the health plan at:. You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of:.

If you do not request a State Fair Hearing by this date, the service the health plan denied will be stopped. If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.

HHSC will give you a final decision within 90 days from the date you asked for the hearing. If you ask for a State Fair Hearing, you can also ask for an External Medical Review where independent health care experts review your request to receive services.

The External Medical Review is an optional, extra step you can take to get your case reviewed for free before your State Fair Hearing. The member may name someone to represent them by contacting the health plan and giving the name of the person the member wants to represent him or her.

If the member does not ask for the External Medical Review within days, the member may lose his or her right to an External Medical Review. If the member asks for an External Medical Review within 10 days from the time the member gets the appeal decision from the health plan, the member has the right to keep getting any service the health plan denied, based on previously authorized services, at least until the final State Fair Hearing decision is made.

If the member does not request an External Medical Review within 10 days from the time the member gets the appeal decision from the health plan, the service the health plan denied will be stopped. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during member appeal processes related to Adverse Benefit Determinations based on functional necessity or medical necessity.

External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.

Once the External Medical Review decision is received, the member has the right to withdraw the State Fair Hearing request. The State Fair Hearing decision can only uphold or increase member benefits from the Independent Review Organization decision. Find out more about filing complaints, appeals, emergency appeals, state fair hearings and external medical reviews by calling one of the following numbers:.

Complaints and Appeals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center.

Manuals Highmark Provider Manual. Provider Information Management Forms. Electronic Forms Electronic Forms are submitted directly to Highmark via this website. Request for Assignment Account - Please use this form when you need to create a billing account for your practice. Addition Request to Existing Assignment Account — Please use this form when needing to update practitioners affiliation to existing assignment account information.

Contract Upload Form Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned. Please use this form to indicate your DEA status.

Return from Leave of Absence Form Please complete this form when the provider is returning from a leave of absence. This will allow for the reinstatement of network participation. Request to be a Highmark Professional Pennsylvania Participating Provider - Please complete this form to have a Highmark Professional Pennsylvania Participating Provider contract sent to your billing practice.