Appeals and Peer to Peer Conversations
Appeals
Providers may request appeals for Prior Authorization Requests and Concurrent Reviews which have been denied. The specific appeals process may vary from that outlined below depending on a Member’s specific benefit plan and state and/or federal regulations.
An appeal can be submitted by a member, provider or facility. Appeals can be submitted up to 180 days from the date of the denial notice from BCBSWY.
Appeals should be submitted in writing. BCBSWY does not require any specific forms to be utilized for submission.
Appeals should include the following components to help with timely determinations:
- A letter stating the denied services and the reason you feel the denial should be overturned, and
- The clinical documentation showing why the denied services should be considered medically necessary or should be considered on an individual basis.
Helpful Hint: Include claim numbers, authorization numbers and other member issue identifiers.
Once BCBSWY receives an appeal request, the appeal documentation is reviewed by medical review staff. Upon determination, BCBSWY will provide written notification to you and the member.
If you are unsatisfied with the determination of your appeal, please call Member Services at 1-800-442-2376 for further assistance.
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:
307-432-2942
Peer to Peer Conversations
Peer to peer conversations are discussions between a physician and a BCBSWY Medical Director regarding denied services. BCBSWY offers Peer to peer conversations for prior authorization requests denied for not demonstrating medical necessity or deemed investigational. Benefit denials are not eligible for a Peer to Peer Conversation.
A Peer to Peer Conversation may be requested by a physician’s representatives 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.
The physician who rendered or requested denied services must 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.
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.
To schedule a peer to peer conversation, please call Provider Support at 888-359-6592. A representative will take your information, and our Medical Review Department will review the request. A BCBSWY representative will contact you to provide an update on the request.