Updated Provider Dispute Process Overview for Government Programs

Posted July 21, 2021

If you are providing service to our Blue Cross Community Health PlansSM (BCCHPSM) and/or Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members, review the updated information regarding how to submit claim disputes to Blue Cross and Blue Shield of Illinois (BCBSIL).

Claim Dispute/Complaint Process:
As you know, when you bill for the services rendered, the claims are sent to the BCBSIL claims department for processing. After processing, the claim will be paid, partially denied or denied. If you feel the claim was incorrectly paid or denied, you can file a claim dispute. BCBSIL gives network and non-network providers at least sixty (60) days to dispute a claim after BCBSIL has partially paid or denied it. You may also dispute recovery request initiated by BCBSIL via this process if you believe the associated claim adjustment was incorrect.

Note: If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected/replacement claim through the claim submission process instead of a claims dispute.

All correspondences sent by providers to dispute a claim requires a valid BCCHP/MMAI Managed Care Organization (MCO) tracking identifier along with a 12-digit Unique Tracking ID or an Enterprise Appeals Application (EAA) Tracking ID.

How to File a Claims Dispute (using 12-digit Unique Tracking ID):

1. Customer Service:

  • File the dispute by calling Customer Service at 1-877-860-2837.
  • You must indicate that you want to file a claims dispute.
  • The Customer Service representative will provide you a 12-digit unique tracking ID and a reference number, which can be used to track the dispute.

2. Fax & Mail:

  • Complete the Provider Claims Inquiry or Dispute Request Form.
  • Include all requested information on the form.
  • Fax or mail the form to the contact information on the form.
  • For status updates, call Customer Service at 1-877-860-2837 and ask for a reference number/12-digit unique tracking ID for your dispute. Allow 7-10 business days before requesting the reference number.

Unique Tracking ID Number Reference Number:
All BCBSIL claim disputes are assigned a 12-digit unique tracking ID number, which will appear in the following format: 193450004656

  • First two digits are the year BCBSIL received the dispute: 19
  • Next 3 digits are the date or the calendar day BCBSIL received the dispute, for example, 345 represents December 11 (the 345th day of the year)
  • The remaining digits uniquely identify the dispute in the BCBSIL system

Note: More information on the use of the unique tracking ID in relation to the Healthcare and Family Services (HFS) Provider Complaint Portal can be found on the HFS website. The 12-digit unique tracking ID described above must be used to submit any complaints regarding claims to the HFS portal. The process described above must be followed for the issue to be accepted by HFS. Submission of any other ticket type to the HFS portal is not appropriate.

How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID

1. Customer Service:

  • File the dispute by calling Customer Service at 1-877-860-2837.
  • You must indicate that you want to file a claims dispute.
  • The Customer Service representative will provide you a reference number, which can be used to track the dispute.

2. Fax & Mail:


The MCO tracking number is required for a provider to submit a complaint through the HFS Provider Complaint Portal. The BCCHP and MMAI MCO tracking identifier is (02) and should be entered as: 02-YYMMDD-EAA number.

Example: 02-200609-530xxxxx (BCCHP/MMAI format for complaint submitted on June 9, 2020).

Response to a Submitted Claims Dispute:
Upon completion of its review, BCBSIL will send a response letter to the submitter detailing the results of the review. The letter will include whether the claim outcome was upheld or overturned along with a reason for this outcome and a reference number: 12-digit unique tracking ID number or EAA tracking ID.

Your dispute may be rejected if it:

  • Does not contain a valid reference number
  • Is a duplicate to an existing claim dispute
  • Was not submitted within the allowable timeframe (60 days) to submit a dispute

Refer to the provider manual for a sample of the claims dispute outcome letters.

Note: If the dispute is not resolved to your satisfaction, you may contact your Provider Network Consultant (PNC). If your claim is adjusted as part of the dispute process you will also receive an Electronic Remittance Advice (ERA) as you would for any claim processed in addition to the response letters outlined below.

Other Requests:
Claims Inquiries – Claims inquiries can be submitted to BCBSIL Customer Service by calling 877-860-2837, fax or mail using the same form as the claims dispute form found here. Claims inquires do not result in a claim outcome review and are intended to address a claim status question, such as denial reason clarification, or reissue of a check.

How to Submit Refunds to BCBSIL

The claims dispute may result in an overpayment from BCBSIL to providers. Providers have the option to submit a refund to BCBSIL or allow BCBSIL to recoup funds from future claim payments.

To refund BCBSIL for overpayment, send the payment along with a copy of the Refund Request letter received from BCBSIL, which includes a remittance form, within 90 days of the date on the letter. To ensure that you are properly credited for the refund, complete the remittance form and mail it along with your check, made payable to Blue Cross and Blue Shield of Illinois. If payment is not received within 90 days, BCBSIL will recoup funds from future claim payments.

For more guidance, refer to the Billing and Reimbursement section of the BCCHP or MMAI Provider Manual.

Service Authorization Disputes:
Service authorization disputes cover the following non-claims scenarios. Use the Provider Service Authorization Dispute Resolution Request Form to file a written pre-service authorization dispute resolution request related to an adverse determination.

NOTE: If you failed to request a prior authorization before service delivery, this process is not for retrospective medical necessity review.

For more detail on the difference between a claims dispute and a service authorization dispute please refer to the Provider Manual.

Appeals

  • Providers do not have separate appeal rights. Members can file an Appeal or can appoint a representative to file on their behalf
  • The BCBSIL Appeal process is used for services that require an authorization and the request has been denied
  • Providers may file an Appeal to have a physician review the determination with an Authorized Representative Designation Form (AOR)
  • More information on appeals can be found by referencing our provider manual found here.

If you have any questions, contact Customer Service at 1-877-860-2837 for BCCHP, or 1-877-723-7702 for MMAI.