Provider Claims Dispute Process Overview for Government Programs
If you are a provider who is contracted to provide care and services to our Blue Cross Community Health PlansSM (BCCHPSM) and/or Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members, you are likely familiar with our provider claims dispute process. For your convenience, we’d like to provide a reminder overview here.
Claim Dispute/Complaint Process:
As you know, when you bill for the services rendered, the claims are sent to the Blue Cross and Blue Shield of Illinois (BCBSIL) claims department for processing. After processing, the claim will be paid, partially denied or denied. If you feel the claim was incorrectly paid or denied, you can file a claim dispute. BCBSIL gives in-network and out-of-network providers at least sixty (60) days to dispute a claim after the Plan has partially paid or denied it. Note: If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected/replacement claim through the claim submission process instead of a claims dispute.
How to File a Claims Dispute
You may file a claims dispute by calling Customer Service or faxing/mailing a form.
- File the dispute by calling Customer Service at 877-860-2837.
- You must indicate that you want to file a claims dispute.
- The Customer Service representative will provide you a reference number, which can be used to track the dispute.
- Complete the Provider Claims Inquiry or Dispute Request Form.
- Include all requested information on the form.
- Fax or mail the form to the contact information on the form.
- For status updates, call Customer Service at 877-860-2837 and ask for a reference number for your dispute.
Unique Tracking ID Number/Reference Number
All BCBSIL claim disputes are associated with a 12-digit number, which will appear in the following format: 193450004656
- First two digits are the year BCBSIL received the dispute: 19
- Next 3 digits are the date or the calendar day BCBSIL received the dispute, for example, 345 represents December 11 (the 345th day of the year)
- The remaining digits uniquely identify the dispute in the BCBSIL system
Note: More information on the use of the unique tracking ID in relation to the Healthcare and Family Services (HFS) Provider Complaint Portal can be found on the HFS website. The reference number described above must be used to submit any complaints regarding claims to the HFS portal. The process described above must be followed for the issue to be accepted by HFS. Submission of any other ticket type to the HFS portal is not appropriate.
Response to a Submitted Claims Dispute
Upon completion of its review, BCBSIL will send a response letter to the submitter detailing the results of the review. The letter will include the reference number, claim number, and describe whether the claim outcome was upheld or overturned along with a reason for this outcome. Note: If the dispute is not resolved to your satisfaction, you may contact your Provider Network Consultant (PNC).
Claims Inquiries – Claims inquiries can be submitted to BCBSIL Customer Service by phone (877-860-2837), fax or mail using the same form as the claims dispute form found here. Claims inquires do not result in a claim outcome review and are intended to address the following:
- Claim status question
- Denial reason clarification
- Reissue of a check
Service Authorization Disputes – Service authorization disputes cover the following non-claims scenarios and should be filed by using the Provider Service Authorization Dispute Resolution Request form.
- Authorization denial, or
- A reduction, suspension or termination of a previously authorized service
For more detail on the difference between a claims dispute and a service authorization dispute refer to the News and Updates on our website.
Appeals – The BCBSIL appeal process is used for services that require an authorization and the request has been denied.
- Members can file an appeal or can appoint a representative to file on their behalf
- Providers may file an appeal to have a physician review the determination with an Authorized Representative Designation Form (AOR)
- More information on appeals can be found by referencing our provider manual found here.