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Provider Billing and Medical Necessity Disputes

Dispute Resolution Process for Physician Billing Disputes

Medical doctors may qualify for a billing dispute external review (BDER) process after exhaustion of the Blue Cross and Blue Shield of Alabama initial internal appeal process. Independent Medical Expert Consulting Services, Inc. (IMEDECS) is our Billing Dispute Resolution Reviewer. This review process seeks to resolve disputes concerning application of coding and payment rules and methodologies for fee for service claims to patient specific factual situations. This includes bundling (fragmented coding), downcoding, application of a Current Procedural Terminology (CPT) modifier, and/or other reassignment of a code. An individual medical doctor or medical doctor group must exhaust the initial internal appeal process and the dispute must exceed $500 to qualify for the external billing dispute process. A filing fee, dependent on the amount in dispute, must also be submitted with the request.

Dispute Resolution Process for Medical Necessity Disputes

This review process seeks to resolve disputes concerning services that are determined to be non-covered due to not being medically necessary, experimental or investigational in nature. The physician must exhaust the post service internal appeal process to qualify for the external review process. The physician may submit a written request to IMEDECS within 60 days from the date of the internal post service appeal non-coverage decision. Physicians seeking external review shall pay a filing fee of $50 if the amount in dispute is $1,000 or less or $250 if the amount in dispute exceeds $1,000. Payment must be submitted with the review request.

Providers can submit a billing or medical necessity dispute resolution by submitting it to the address or fax number below:

Attention: Jimilou Budusky
100 West Main Street, Suite 310
Lansdale, Pennsylvania 19446
Telephone: 215-855-4633, ext. 324
Fax: 215-855-5318

Providers may also access the Blue Cross and Blue Shield of Alabama Provider Appeals section on our website for additional information on these type disputes.