BCBS Coding and Payment Rule Appeals

Coding and Payment Rule Appeals

A Coding and Payment Rule Appeal is a written request from a licensed health care practitioner for
reconsideration of a health care claim based on BCBSF’s application of its coding and payment rules and
methodologies (including without limitation any bundling, downcoding, application of a CPT modifier,
and/or other reassignment of a code by BCBSF). These appeals apply to claims filed by M.D.s and D.O.s
in connection with health care services rendered to a specific individual covered under a policy or plan
insured or administered by BCBSF. A Coding and Payment Rule Appeal does not refer to pre-service
review, concurrent review, claim status requests, and other types of provider communication, such as
telephone inquiries.

Claims processed after the implementation date, regardless of service date(s), will process according to
the updated version. No retrospective claim payment changes are made for processing changes that are
the result of new code editing rules.

If an exception to the rule above applies or, a physician is appealing a case specific exception, the appeal
should be sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).
• A written explanation supporting the procedure code(s) appealed.
• A copy of the remittance advice attached.
• The necessary medical documentation (e.g., operative report, physician orders, history and physical)
as indicated by the reason for the reduction or the denial on the remittance advice.

If a physician disagrees with BCBSF’s edit logic overall (not case-specific), provide a written statement of
the appeal, along with the following information:

• The completed Provider Appeal Form.
• Documentation normally required for a medical review.
• Written explanation supporting the procedure codes submitted.
• Documentation from a recognized authoritative source that supports your position on the procedure
codes submitted (optional).

Send Coding and Payment Rule Appeals to:

Blue Cross and Blue Shield of Florida
Provider Disputes Department
P.O. Box 44232
Jacksonville, FL 32231-4232

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