Instructions To Complete The Mountain State Blue Cross Blue Shield by gabyion

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									                                  Instructions To Complete The Mountain
                                  State Blue Cross Blue Shield External
                                  Appeal Process Form For MDs and DOs


As of March 6, 2009, the External Appeal Process is available to physicians who are class members of
the Love Settlement Agreement (“the Settlement Agreement”) and the physician groups comprised of
such physicians. The External Appeal process is intended to provide an additional level of appeal for
post-service, medical necessity denials for MDs and Dos who are class members of the Settlement
Agreement.

Please be advised, physicians must exhaust all Mountain State Blue Cross Blue Shield’s (Mountain
State) provider internal appeal processes and no member appeal may have been filed for medical
necessity denials before submitting an appeal to the External Appeal Process. This requirement will be
deemed to have been satisfied if Mountain State has responded to your appeal, and their response
indicates internal review has been exhausted. Physicians must submit their External Appeals request
directly to National Medical Review, Inc. no later than sixty (60) calendar days after exhausting Mountain
State’s internal provider appeal process.

If an MD or DO who is a member of the Love settlement agreement disagrees with a denial decision and
has exhausted all of Mountain State’s internal provider appeal processes and no member appeal has
been filed, they may submit to their appeal to the External Appeal Process.

Requirements to Appeal a Mountain State Decision Using the External Appeal Process:

    •   You must be a class member of the Love Settlement Agreement who did not opt out.
    •   You must have exhausted all internal provider medical necessity appeal processes.
    •   No member appeals may have been filed.
    •   Your appeal must arise from a medical necessity denial for services provided to a
        Mountain State member.
    •   You must have initiated a provider expedited appeal and/or a provider standard appeal
        with Mountain State and received a written denial response that you wish to have
        reconsidered.
    •   The External Appeal must be filed within sixty (60) calendar days of the date of the final
        Mountain State denial notification letter.
    •   You must submit the proper filing fee to the vendor by check. Filing fee information listed
        below.
    •   You must complete the Mountain State Blue Cross Blue Shield External Appeal Form for
        MDs and DOs and the External Appeal Process Agreement listed below for the appeal
        and return to National Medical Reviews, Inc. with any additional documentation you
        would like to have considered, including a copy of the original denial notification.
    •   (For more information about this process, see section 7.11(e) of the Settlement
        Agreement –visit http://www.hmosettlements.com/pages/Mountain State .html for
        Settlement Agreement).

Filing Fees are as follows:

    •   If the amount of the denied service is $1,000 or less, the filing fee shall be equal to $50.
    •   If the amount of the denied service exceeds $1,000, the filing fee shall be equal to $250.

    If the Physician prevails, the filing fee will be refunded.




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                               Instructions To Complete The Mountain
                               State Blue Cross Blue Shield External
                               Appeal Process Form For MDs and DOs

What to submit to External Appeal Vendor:

   •   Copy of Mountain State’s final medical necessity appeal denial letter;
   •   Mountain State External Appeal Agreement For MDs and DOs and the Mountain State External
       Appeal Process Form For MDs and DOs. Copies of these documents can be located by choosing
       the Provider dropdown at www.msbcbs.com;
   •   All supporting documentation that you would like to be considered by National Medical Reviews,
       Inc.; and
   •   Appropriate Filing Fee.

Please attach the above documents to the External Appeal Process Form (which can be downloaded by
choosing the Provider dropdown at www.msbcbs.com). Follow the instructions noted at the top of this
External Appeal Process form which includes the name and address of the vendor:



                                   National Medical Reviews, Inc.
                                     Attention: Meredith Merlini
                                  8 Neshaminy Interplex, Suite 207
                                         Trevose, PA 19053
                                      Phone: (800) 283-8196
                                        Fax: (215) 352-7801



Upon receipt, National Medical Reviews, Inc. may request additional documentation for the physician or
physician group. The additional documentation must be submitted within 30 calendar days of National
Medical Review, Inc’s request.




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                                 Instructions To Complete The Mountain
                                 State Blue Cross Blue Shield External
                                 Appeal Process Form For MDs and DOs
Frequently Asked Questions


1. Q.    Who is eligible for submissions to National Medical Reviews, Inc?
   A.    MD/DOs who are class members of the Love Settlement Agreement, who have exhausted their
         Mountain State internal provider appeals processes, and no member appeal has been filed for
         the denial.

2. Q.    Is the filing fee required?
   A.    Yes.

3. Q.    Where do I send payment for the filing fee?
   A.    The filing fee which is sent to National Medical Reviews, Inc., is required when the External
         Appeal Process form is submitted.

4. Q.    What happens to my filing fee if I win the appeal?
   A.    If the requesting provider prevails, the filing fee will be returned to the requesting provider.

5. Q.    How long before a resolution is received from National Medical Reviews, Inc?
   A.    Once National Medical Reviews, Inc. receives the appeal, they will determine that all eligibility
         requirements were met (e.g., internal appeals exhausted). National Medical Reviews, Inc. then
         has thirty (30) days from receipt of all clinical information to review the appeal and make a
         decision.

6. Q.    Is National Medical Reviews, Inc.’s decision binding?
   A.    National Medical Reviews, Inc.’s decision is binding on both the Provider and Mountain State.




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