How to Appeal a Claim

To appeal a claim payment or denial, follow these steps:

Step 1: Contact Us

Call the Member Services phone number on your member ID card. If your concern is not resolved through a discussion with a CareFirst BlueChoice representative, you may submit a written appeal.

Note: Virginia members who wish to appeal an adverse benefit decision that is related to the treatment of cancer may be entitled to an expedited external review without first exhausting the internal review process.

Step 2: Submit A Written Appeal

CareFirst BlueChoice must receive your written appeal within 180 days of the date of notification of the denial of benefits or services. Submit a letter addressed to the Member Services Department describing your reasons for appeal. Send the letter to the address that appears on your Member ID card. If you need help in finding the address, call Member Services.

In the letter include:

• Member name and ID number
• Provider name
• Date(s) of service
• Admission and discharge date if applicable
• A copy of the original Explanation of Benefits, voucher or bill
• Medical records (e.g. Emergency room records or X-ray reports)

In the event you are unable to put the request in writing, a Member Services representative can assist you. Or, ask your provider if they can submit this information for you.

Step 3: Appeal Decisions

All appeal decisions will be sent to you in writing and will include a detailed explanation about the decision, as well as any documentation to support the decision. You will also receive information on next steps you may take if you are not satisfied with the appeal decision.

Many members have a right to an independent external review of any final appeal or grievance decision.

* Please note that state mandates may alter the steps above. Refer to your Evidence of Coverage for more information regarding your appeal process.