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Questions & Answers
Appeals and Peer to Peer Conversations

Appeals Q & A

BCBSWY accepts appeal requests for Prospective Requests (Pre-Certification), Pre-Admission Reviews, Concurrent Reviews, and Claims which have been denied.┬áThe specific appeals process may vary from that outlined below depending on a Member’s specific benefit plan and state and/or federal regulations. If you need assistance submitting an appeal, please call Member Services at 1-800-442-2376.

Who can submit an appeal?

An appeal can be submitted by a member, provider or facility.

When can an appeal be submitted?

Appeals can be submitted up to 180 days from the date of the denial notice from Blue Cross Blue Shield of Wyoming. A denial notice is a denial letter or an Explanation of Benefits detailing the denied services.

How do you submit an appeal?

Appeals should be submitted in writing. BCBSWY does not require any specific forms be utilized for submission. Appeals should be sent to BCBSWY by mail or fax.

Mail:
Member Services
Blue Cross Blue Shield of Wyoming
PO Box 2266
Cheyenne, WY 82003-2266

Fax:
307-634-5742

What should be included with your appeal?

Appeals should include the following components to help with timely determinations:

  1. A letter stating the denied services and the reason you feel the denial should be overturned, and
  2. The clinical documentation showing why the denied services should be considered medically necessary or should be considered on an individual basis.

After submitting your appeal, what happens next?

Once BCBSWY receives an appeal request, the appeal documentation is reviewed by the medical review staff member who made the initial denial determination. If it is determined that the initial denial is still appropriate, the appeal is reviewed again by other medical review staff. Upon determination, BCBSWY will provide notification to you and the member (as appropriate).

What happens if your appeal is denied?

If you are unsatisfied with the determination of your appeal, please call Member Services at 1-800-442-2376 for further assistance.

Peer to Peer Conversations Q & A

Peer to Peer Conversations are discussions between a physician and a BCBSWY Medical Director regarding denied services. BCBSWY offers Peer to Peer Conversations for denials or appeals of Prospective Requests (Pre-Certifications) and Concurrent Reviews only. Peer to Peer Conversations are conducted when services were denied for not demonstrating medical necessity or deemed investigational. Benefit denials are not eligible for a Peer to Peer Conversation.

Who requests a Peer to Peer Conversation?

A Peer to Peer Conversation may be requested by a physician’s representative who has access to the following information:

  • Physician’s schedule
  • Physician’s general rationale for a conversation regarding the denial

The representative will also be asked to confirm that the physician has reviewed the BCBSWY denial documentation including any applicable Medical Policies.

Who participates in a Peer to Peer Conversation?

The BCBSWY Medical Director and the physician who rendered or requested denied services should participate in the Peer to Peer Conversation. If the physician is unavailable for a conversation, a colleague may be allowed on a case by case basis.

When should you request a Peer to Peer Conversation?

Peer to Peer Conversations may be requested up to ten calendar days from the date of the denial notice from BCBSWY. BCBSWY may accept Peer to Peer Conversations past ten calendar days on a case by case basis.

How do you schedule a Peer to Peer Conversation?

To schedule a Peer to Peer Conversation, please call Member Services at 1-800-442-2376. We will take your information and within one business day, a representative from our Medical Review Department will call to schedule a time for the conversation.

Questions?
We're here to help.

800-442-2376
Monday-Friday 8 a.m. - 5 p.m.

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