| BCBSRI Internal Complaint and Appeal Process
BCBSRI will make every reasonable effort to resolve administrative complaints and appeals from our physicians/providers, following our standard procedures. This section focuses on outlining the definitions of a complaint and an appeal, as well as explaining the procedures for filing and resolving complaints and appeals from providers regarding provider issues.
What classifies as a complaint?
A provider complaint is an oral or written expression of dissatisfaction by the provider regarding an actual or alleged circumstance that gives the provider cause for protest, such as dissatisfaction with any of the following:
- Timeliness of payment
- Payment policies
- Corporation materials
- Timeliness of responses to requests for information
What classifies as an appeal?
A provider administrative appeal is an oral or written request from the provider asking the Corporation to reconsider a full or partial administrative denial.
A medical appeal is a request for the Corporation to reconsider a full or partial denial of a prior authorization or a claim for services that the Corporation has determined to be either not medically necessary or experimental/investigational in nature.
How do I file a complaint or an appeal?
Complaints and appeals may be filed with BCBSRI by contacting the Physician and Provider Service Center at (401) 274-4848 or 1-800-230-9050 or by submitting a request in writing to:
Grievance and Appeals Unit
Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, RI 02903-2699
The Provider Appeal Request Form can also be used to submit a written appeal.
Submission Timeframes
Providers must submit their administrative appeals within 60 days of the initial notice of a denied claim or service request. Complaints are not held to a submission timeframe.
Acknowledgment Timeframes
The Grievance and Appeals Unit will acknowledge the complaint or appeal verbally or in writing within 10 business days of receipt. The acknowledgement notification will include the expected timeframe for a response.
Determination Timeframes
Every effort will be made to resolve the issue within the following timeframes:
- Complaints – 30 business days
- Administrative appeals – 60 calendar days
- Medical appeals – 30 calendar days
The provider is informed of the outcome or decision of the complaint or appeal in writing.
Appointment of Representative
When filing a complaint or appeal on behalf of a member who is over 18 years of age, one of the following is required:
Note: When submitting an appeal on behalf of a BlueCHiP for Medicare member, please use a CMS -1696 Appointment of Representative form.
For more detailed information on the provider complaints and appeals process, please refer to Chapter 3 of the Provider Manual. For information on the member complaints and appeals process, including how to file a complaint or appeal on behalf of a member, please refer to Chapter 5 of the Provider Manual.
BCBSRI's External Billing Dispute Review Process is also available to all eligible physicians upon conclusion of the internal appeals process.
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