Pre service and post service Adverse Determination Appeals

Adverse Determination Appeals

A provider may file a written request with BCBSF for reconsideration of a denial of payment because a
proposed, or actual, health care service or supply was not medically necessary, was experimental or
investigational, was supportive of an experimental or investigational, or was supportive of a not medically
necessary procedure (“Adverse Determination Appeal”). An Adverse Determination Appeal can be of
pre-service claims or a post-service claim if the requirements outlined below are met. An Adverse
Determination appeal must be in writing and is not triggered by claim status requests or telephone
inquiries regarding the application of benefits or allowed amount.


Pre-Service Adverse Determination Appeals

A physician (i.e., Medical Doctor or Doctor of Osteopathy) or physician group can appeal a pre-service
Adverse Determination (Pre-Service Appeals), if they are appealing on behalf of a BCBSF member.
Except for urgent Pre-Service Appeals, authorization must be obtained from the BCBSF member in
writing. Pre-Service appeals will be handled by BCBSF under the appeal process available to its member
based on the terms of that member’s contract or policy and the applicable state and federal laws and
regulations.


Post-Service Appeals

A provider can appeal a post-service Adverse Determination (Post-Service Appeal). An Adverse
Determination Post-Service Appeal must be submitted in writing within one year of date of payment and
sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).
• A copy of the remittance advice.
• 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.
The provider or provider group may not initiate an internal Post-Service Appeal of any denied service or
supply if:
• BCBSF’s member (or his or her representative) or the provider or provider group filed a Pre-Service
Appeal pertaining to the same denied service; or
• BCBSF’s member (or his or her representative) is currently seeking or has sought a review or filed
litigation related to the same denied service. In the event both BCBSF’s member (or his or her
representative) and the provider or provider group seek review of the same denied service, BCBSF’s
member appeal shall go forward and the provider or provider group appeal will be dismissed.

Send Adverse Determination internal appeals to:
Blue Cross and Blue Shield of Florida
Provider Disputes Department
P.O. Box 44232
Jacksonville, FL 32231-4232