Appeal Address for Major BCBS Plans

Local BCBS Plans	Appeal Address
BCBS of Alabama	P.O. Box 362025 Birmingham, AL 35236 Fax: 205 220-9560
Premera Blue Cross (Alaska)	P.O. Box 91102 Seattle, WA 98111-9202 Fax: 425-918-5592
BCBS of Arizona	P.O. Box 13466 Mail Stop A116 Phoenix, AZ 85002-3466
Arkansas BCBS	P.O. Box 3688 Little Rock, AR 72203‐3688
Blue Shield of California	P.O. Box 4310 Woodland Hills, CA 91365-4310 Fax: 818-234-1089
Highmark BCBS Delaware	P.O. Box 8832 Wilmington, DE 19899-8832
BCBS of Florida	P.O. Box 1798 Jacksonville, FL 32231
BCBS of Georgia	Attn: Provider Appeals P.O. Box 9907 Columbus, GA 31908
Hawaii Medical Service Association (BCBS of Hawaii)	HMSA Attn: Appeals Coordinator P.O. Box 1958 Honolulu, HI 96805-1958
Blue Cross of Idaho	Appeals and Grievance Coordinator Blue Cross of Idaho P.O. Box 7408 Boise, ID 83707
BCBS of Illinois	P.O. Box 805107 Chicago, IL 60680-4112
BCBS of Kansas	1133 SW Topeka Boulevard Topeka, KS 66629-0001
BCBS of Louisiana	Appeals and Grievance Coordinator P. O. Box 98045 Baton Rouge, LA 70898-9045
BCBS of Massachusetts	ProviderAppeals P.O. Box 986065 Boston, MA 02298
BCBS of Michigan	Grievance and Appeals Department P.O. Box 2627 Detroit, MI 48231-2627
BCBS of Minnesota	Appeals or Claim Adjustments P.O. Box 64560 St Paul, MN 55164-0560
BCBS of Mississippi	For Appeal, need to use Electronic Appeals tool on myAccessBlue
BCBS of Montana	P.O. Box 4309 Helena, MT 59604
BCBS of Nebraska	P.O. Box 3248 Omaha, NE 68180-0001
Horizon BCBS of New Jersey	Appeals Department Horizon Blue Cross Blue Shield of NJ P.O. Box 10129 Newark, NJ 07101-3129
Empire BCBS (New York)	Attn: Physician Services PO Box 1407 Church Street Station New York, New York 10008-1407
BCBS of North Carolina	Provider Appeals - Level I Network Support Department PO Box 2291 Durham, NC 27702-2291
BCBS of Oklahoma	P.O. Box 3283 Tulsa, OK 74102-3283
Regence BCBS of Oregon	P.O. Box 1271, MS C7A Portland, OR 97201-1271
Highmark BCBS  (Pennsylvania)	Grievances and Appeals Appeals PO Box 890174 PO Box 890178 Camp Hill, PA 17089-0174
BCBS of Rhode Island	Grievance and Appeals Unit 500 Exchange Street Providence, RI 02903-2699
BCBS of South Carolina	ATTN: medical appeals P. O. Box 100605 Columbia, SC 29260-0605 Fax: 803-264-4204
BCBS of Texas	P.O. Box 660044 Dallas, Texas 75266-0044
Regence BCBS of Utah	P.O. Box 1271, MS C7A Portland, OR 97207-1271
BCBS of Vermont	P.O. Box 186 Montpelier, VT 05601 Fax (802) 225-7698
BCBS of Wyoming	P.O. Box 2266 Cheyenne, WY 82003 Fax: (307) 634-5742
Premera Blue Cross (Washington)	P.O. Box 91102 Seattle, WA 98111-9202 Fax: 425-918-5592

How to get Authorization from OrthoNet for Physical Therapy and Occupation therapy for Uniformed Services Family Health Plan?

OrthoNet is Uniformed Family Service Health Plan's network manager for all outpatient physical and occupational therapy services in New York and New Jersey. OrthoNet has also been delegated as claims administrator for the in-network claims covered by this arrangement.

We need to submit the therapy request form to OrthoNet and need to fill the below information. Its need to be fax #1-800-874-0452

Therapy Provider Information

• Facility Name
• Street Address
• City
• State
• Zip
• Telephone Number
• Return Fax Number
• OrthoNet Provider ID Number

Patient Information

• First Name
• Last Name
• Patient ID Number
• Date of Birth

Request Information

• Service Type
• Initial Evaluation Date
• Diagnosis Code
• Requested # of Visits

You will find this Authorization template in this link http://www.orthonet-online.com

Value Options has partnered with PaySpan for Electronic Payment Deposit

Value Options joined with PaySpan to provide electronic deposit for Mass Behavioral Health Partners (MBHP) providers. Registration code mailed to all participating providers or we can call PaySpan @ 877-331-7154 to get the registration to setup Electronic Deposit.

Due to this Electronic Deposit implementation, Value Options no longer mails Paper (Provider Summary Vouchers) PSVs to providers however it will be available online at https://www.valueoptions.com/pc/eProvider/providerLogin.do otherwise providers can request PSVs by calling faxback number 866-409-5958. If a provider wants to get the PSV through faxback service, check date, the reference number and the check amount required.

MedSolutions has partnered with Passport Health Plan to provide authorization services for outpatient elective procedures.

Effective from October 1, 2012 date of service Passport Health Plan member require prior authorization from Med Solutions for all outpatient elective CT, MR, PET and numeric cardiac Imaging studies.
 
Services require authorization

All outpatient, non-emergent, diagnostic imaging services including

• CT / CTA
• MRI / MRA
• PET
• NCM / MPI

Services do not require authorization

• Inpatient radiology
• Radiology testing done in the Emergency Room
• 23 hour observation

How can we request authorization from MedSolutions?  

We can request authorization from MedSolutions in three ways as below.

• Through Website   - www.medsolutionsonline.com (Registration required)
• Through Phone      - 877 791 4099 (Availed on Monday to Friday at 8AM to 9PM EST)
• Through Fax          - 888-693-3210 (we need to MedSolutions fax request form only. It’s available in their website)

What kind information requires for authorization request?
 
To request authorization by website, phone or fax below details are required.  

• The patient’s name & address
• The current patient ID
• The working or differential diagnosis
• Prior tests, lab work and/or imaging performed related to this diagnosis
• Notes from the patient’s last visit related to the diagnosis
• Type and duration of treatment performed to date for the diagnosis

Authorization will be faxed to requesting provider upon approval however there is no changes in the claim submission. So we can submit the claim continuously to Passport Health Plan but the questions regarding authorization should be communicated with MedSolutions only.

How to get Authorization from OrthoNet for Spinal Surgery and Pain Management Programs for Humana?

Humana has delegated the precertification of spine surgery in any setting as well as pain management procedures (not including trigger point injections) in all settings to OrthoNet. These procedures and their CPT codes are listed on the applicable Humana Prior Authorization List which can be viewed at Humana’s website

We need to submit the Spinal Surgery and Pain Management Programs request form to OrthoNet and need to fill the below information. Its need to be fax #1-800-605-5345

Provider Information

• Provider Name
• Street Address
• City
• State
• Zip
• Telephone Number
• Fax Number
• Fax Date
• Number of Pages faxed
• NPI
• Provider Tax Id number

Patient Information

• First Name
• Last Name
• Humana Member ID Number
• Date of Birth
• Diagnosis code

Request Information

• Request for Pain Region
• Spinal Region
• Has the patient had prior spinal surgery?
• Is this the first epidural steroid or facet injection for this patient?
• Is the MR/CT report attached to this request?
• CPT Code(s)
• Requested Facility for surgery/Procedure(s)
• Anticipated Date of Service(s)
• City
• State
• Telephone Number

You can retrieve this Authorization template in http://www.orthonet-online.com

How to get Authorization from OrthoNet for Physical Therapy and Occupation therapy for Humana?

Humana has delegated Medical Management responsibilities for physical, occupational and speech therapy services to OrthoNet for HMO, POS, EPO, PPO and Medicare Advantage members. OrthoNet’s scope of responsibility includes the management of the prior-authorization process for outpatient therapy services.

We need to submit the therapy request form to OrthoNet and need to fill the below information. Its need to be fax #1-800-863-4061

Therapy Provider Information

• Facility Name
• Street Address
• City
• State
• Zip
• Telephone Number
• Fax Number
• NPI
• Provider Tax Id number

Patient Information

• First Name
• Last Name
• Humana Member ID Number
• Date of Birth
• Diagnosis Code

Request Information

• Service Type
• Initial Evaluation Date
• If this request for post or pre-operative therapy visits
• If this is a Humana Medicare Advantage PFFS member, is this request for an Advanced Coverage Determination

You can retrieve this Authorization template in http://www.orthonet-online.com

How to get Authorization from OrthoNet for Physical Therapy and Occupation therapy for GEHA (Government Employees Health Association, Inc.)

OrthoNet has been authorized by GEHA (Government Employees Health Association, Inc.) to administer the review of physical, occupational and speech therapy services for its members nationwide. In addition, OrthoNet provides GEHA with concurrent review services for musculoskeletal admissions in post-acute settings. These programs cover all GEHA members nationwide except for those members residing in North Carolina, South Carolina, Georgia, and Pennsylvania

We need to submit the therapy request form to OrthoNet and need to fill the below information. Its need to be fax #1-877-304-4398

Therapy Provider Information

• Facility Name
• Street Address
• City
• State
• Zip
• Telephone Number
• Fax Number
• GEHA Provider ID Number
• NPI
• Provider Tax Id number

Patient Information

• First Name
• Last Name
• GEHA Member ID Number
• Date of Birth

Request Information

• Service Type
• Initial Evaluation Date
• Diagnosis Code
• If this request for post or pre-operative therapy visits
• Requested # of Visits

You will find this Authorization template in this link http://www.orthonet-online.com

How to get Authorization from OrthoNet for Physical Therapy and Occupation therapy for Empire WellChoice members living in state of New York and New Jersey?

Empire WellChoice has delegated to OrthoNet medical management responsibilities for physical and occupational therapy services for HMO, HMO/POS, PPO, EPO, Child Health Plus and certain ASO account members in the New York and New Jersey regions..

We need to submit the therapy request form to OrthoNet and need to fill the below information. Its need to be fax #1-866-800-7485

Therapy Provider Information

• Facility Name
• Provider First Name
• Provider Last Name
• Street Address
• City
• State
• Zip
• Telephone Number
• Fax Number
• Provider ID Number

Patient Information

• First Name
• Last Name
• Member ID Number
• Date of Birth

Request Information

• Service Type
• Initial Evaluation Date
• Diagnosis Code
• If this request for post or pre-operative therapy visits
• Requested # of Visits

You will find this Authorization template in the below link: http://www.orthonet-online.com