When a claim for services is denied, you will receive (through the mail or online) an Explanation of Benefits (EOB) listing the reason. You have the right to file an appeal to request review of a denial in whole or in part. The first step is to submit an appeal in writing.
How to appeal a denied claim
If a claim is denied and you would like further information, follow these steps:
Step 1 Go to the member dashboard in Blueprint Portal to access your claims history, policy information and EOB.
Step 2 Call the customer service number on the back of your ID card if you have questions about the denial.
Step 3 Complete your written appeal request and include the following or download a form on Blueprint Portal:
Claim number being appealed and date of service
Member’s name and health plan ID number
Provider’s name
Reasons why you believe that the claim was incorrectly denied
Your request should also include any medical records relevant to the appeal, such as copies of any paperwork like an EOB, medical bills, etc
Sign and date
Step 4 Send your appeal within 180 days (about 6 months)* after the EOB is mailed to you or you access it online. You can mail, fax or email** the signed written request to your health plan.
When to expect a response
A review of the claim will be conducted to ensure there has not been an error in processing it. You will have a final decision mailed to you within 60 days after your request is received unless unusual circumstances require more review.
*Timeframes and appeals processes vary by health plan. Please call the number on the back of your ID card to speak with a customer service representative.
**The mailing address, fax number and email address may vary by plan. Be sure to check your EOB to ensure you have the correct information.