Provider Clinical Appeal Instructions and Form Form

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Instructions for the Provider Clinical Appeal Form

Physicians and Providers may question the outcome of how a claim processed via a provider appeal. The Provider Clinical Appeal Form should be used when clinical decision making is necessary:  Utilization Management
 Adverse Determination  Coding and Payment Rule

Please review the instructions for each category below to ensure proper routing of your appeal.

Utilization Management Appeals
The appeal must relate to an authorization or precertification problem that affected a claim payment.

Complete the form in entirety.
 Check the “Utilization Management” box under Appeal Type
 Check the appropriate box for the Utilization Management appeal reason, either “Authorization” or “Precertification”
 Enter the applicable authorization or precertification number
 Complete sections 1-4. Please describe the authorization or precertification issue that affected your claim payment in as much detail as possible.
 Supporting documentation must be submitted.

Adverse Determination Appeals (Medical Necessity or Experimental/Investigational) The appeal must relate to a “Not Medically Necessary” or “Service is Experimental or Investigational in Nature” claim denial.

Complete the form in entirety.
 Check the “Adverse Determination” box under Appeal Type.
 Complete sections 1-4. Please describe the issue in as much detail as possible.
 Supporting documentation must be submitted.

Coding and Payment Rule Appeals The appeal must relate to the application of coding, payment rules and methodologies for professional service claims (including without limitation any bundling, down-coding, application of a CPT® modifier, and/or other reassignment of a code by Florida Blue) in connection with health care services rendered to a specific individual covered under a policy or plan insured or administered by Florida Blue or Florida Blue HMO, such as:

 Procedure bundling  The appropriate amount of payment, as determined by Florida Blue or Florida Blue HMO when two or more CPT codes are billed together. Such payment rules may include:
 Duplicate Procedures  Multiple Surgery Guidelines  Coordination of Benefits  Multiple Imaging Edits  Multiple Evaluation and Management Service Edits

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Instructions for the Provider Clinical Appeal Form (Continued)

 Whether a payment-enhancing modifier is appropriate. Such payment enhancing modifiers are:  Assistant Surgeons (includes modifiers 80, 81 and 82)
 Modifier 22 Unusual Procedural Services
 Modifier 23 Unusual Anesthesia
 Modifier 24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
 Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
 Modifier 57 Decision for Surgery  Modifier 59 Distinct Procedural Service
 Modifier 62 Two Surgeons
 Modifier 66 Surgical Team

Complete the form in entirety.
 Check the “Coding and Payment Rule” box under Appeal Type.
 Complete sections 1-4. Please describe in as much detail as possible the coding, payment rule or modifier that is the subject of your appeal.
 Supporting documentation must be submitted.

Mail all appeal types above (Utilization Management, Adverse Determination, Claim and Payment Rule), to:

Florida Blue Provider Disputes Department P.O. Box 44232 Jacksonville, FL 32231-4232

1 November 2014 900-522-1114

Provider Clinical Appeal Form

When submitting a provider appeal, please complete the form in its entirety in accordance with the instructions contained in Florida Blue’s Manual for Physician and Providers available online at floridablue.com. Select Providers, then Provider Manual. Appeals must be submitted within one year from the date on the remittance advice. Please send only one claim per form.

Date
____

Reason for Appeal (check one)

   Utilization Management 
   Authorization or Precertification

Number:

   Adverse Determination 
   (Medical Necessity or

Experimental/Investigational)

   Coding and Payment Rule

1. Provider Information

   Provider Name National Provider Identifier (NPI) Florida Blue Provider Number Street Address City

   State Zip Telephone Number Fax Number Contact Name

2. Patient Information Last Name First Name Member/Contract Number (alphas and numeric) Date of Birth

3. Claim Information

   Claim Number Date(s) of Service (MM/DD/YYYY)
   (From)
   (To) Total Billed Amount Procedure Code(s) being Appealed

4. Appeal Explanation

   Supporting Documentation: The following supporting documentation must be attached to this form:

5. Copy of the remittance advice or member’s explanation of benefits. Indicate the code(s) or service(s) being appealed.

6. All medical documentation related to the appeal (medical records, operative report, etc.).

   **Please note effective immediately, the related medical documentation must be submitted with the appeal or it will not be considered a valid appeal.

   Mail to: Florida Blue Provider Disputes

   P.O. Box 44232

   Jacksonville, Florida 32231-4232