Clinical Reviews are conducted on utilization management denied requests. You can request review of utilization management decisions when a request for either an inpatient or outpatient service is denied.
Administrative appeals/claims reviews are conducted on claim-based denials. To request a claim adjustment for a service previously reviewed, you must submit a written request.
|If we denied a:||Then request a:||By:|
|Pre-authorization request for an inpatient or outpatient service
(sometimes the denial is called an adverse determination)
|Clinical review||Referring to our Blue Book provider manual|
||Sending us the Request for Claim Review Form within one year of the date the claim was denied. You can submit up to two appeals per denied service within one year of the date the claim was denied.
Completed forms should be mailed to:
Blue Cross Blue Shield of MA