![]() ![]() There are no annual benefit maximum amounts.Deductibles: individual $100 family $200.If you see a non-Prudent Buyer physician, the plan pays 70 percent after the deductible has been met.The plan pays 80 percent after deductible has been met. If you see a Prudent Buyer physician, you may see any physician you choose.You decide at the time you need healthcare services whether to see a network provider or a non-network provider.This plan has a California-based preferred provider network of physicians and hospitals that have negotiated with Anthem Blue Cross to provide discounted services to participants.The physician or facility may request an expedited appeal by calling the number on the back of the member's ID card.ConditionCare Disease Management Program:Ĭontact your insurance carrier for plan booklets, claim forms, and billing questions. Urgent care or expedited appeals may be requested if the member, authorized representative or physician feels that non-approval of the requested service may seriously jeopardize the member's health.Review is conducted by a non-medical appeal committee. Relates to administrative health care services such as membership, access, claim payment, etc. A non-clinical appeal is a request to reconsider a previous inquiry, complaint or action by BCBSMT that has not been resolved to the member's satisfaction.A clinical appeal is a request to change an adverse determination for care or services that were denied on the basis of lack of medical necessity, or when services are determined to be experimental, investigational or cosmetic.Brief descriptions of the various member appeal categories are listed below. Written or verbal authorization from the member is required with the exception of urgent care appeals. The physician/clinical peer review process takes 30 days and concludes with written notification of appeal determination.Ī member appeal may be submitted by the member or their authorized representative, physician, facility or other health care practitioner.A routing form, along with relevant claim information and any supporting medical or clinical documentation must be included with the appeal request.Appeals may be initiated in writing or by telephone, upon receipt of a denial letter and instructions from BCBSMT.Most provider appeal requests are related to a length of stay or treatment setting denial. This is different from the request for claim review request process outlined above. AppealsĪ provider appeal is an official request for reconsideration of a previous denial issued by the Blue Cross and Blue Shield of Montana (BCBSMT) Medical Management area. ![]() ![]() Log on to Availity ® to request a claim review and initiate a negotiation for NSA-eligible services. Follow instructions on the form and mail to the address indicated.Ĭlaims for certain services may be eligible for payment review under the No Surprises Act (NSA) if you don’t have a contract with us.To request a review, complete the Claim Review Form.After adjudication, additional evaluation may be necessary (such as place of treatment, procedure/revenue code changes, or out-of-area claim processing issues). ![]()
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