The Grievance Process: For Providers
BCBSAZ contracted providers and non-contracted providers may participate in the
Provider Grievance Process (the “Grievance Process”), which has two levels of review.
BCBSAZ member grievances are processed through the BCBSAZ Member Grievance Process.
Members of other Blue Cross Blue Shield plans should contact their home plans to
submit an appeal or grievance.
The Grievance Process applies to payment disputes and other non-payment disputes,
including but not limited to systemic or operational problems, quality assurance
problems or network adequacy problems unrelated to the provider’s contract status.
The Grievance Process is not intended to limit provider participation in the Health
Coverage Appeal Process, described above. Providers appropriately acting on behalf
of members may submit an appeal to BCBSAZ to the extent permitted under the Health
Coverage Appeal Process and ERISA.
Providers have the opportunity to submit written comments, documents, or other information
in support of their grievance. Grievances will be conducted by a person different
from the person who made the initial decision. No deference will be afforded to
the initial determination.
If a provider’s contract is denied, terminated, or not renewed, different processes
administered through the BCBSAZ Credentialing Department will apply.
Provider Grievances include:
- Whether the claim was clean
- Failure to timely pay claim
- Amount paid (bundling software)
- Amount paid (other than bundling software)
- Amount or timeliness of interest payment
- Coverage under enrollee’s policy (e.g. benefit exclusion, medical necessity, etc.)
- Adjustment request
- Network adequacy (other than the provider’s contract status)
- Systemic or operational problems
- Other
Please Note: Notwithstanding any other provisions
in this Grievance Process, if a provider and BCBSAZ cannot reach agreement on price
or contractual language in an initial contract negotiation or a negotiation to renew
or continue a contract, a negotiation regarding additional reimbursement and/or
a provider’s request to add additional lines of business to an existing contract,
this failure to agree is not subject to this Grievance Process or any other BCBSAZ
grievance or appeals process.
Grievance (Level 1)
A provider must file a written Provider Level 1 Grievance request to BCBSAZ within
one year of the denial or other notification, or date of the occurrence if no notification
was sent. BCBSAZ may extend this one-year time period for good cause or if a longer
period is required by state or federal law.
Written Level 1 Grievance requests should include the following:
- A written explanation of the issue
- Documentation that supports the member’s/provider’s position, such as medical records,
operative reports, or office notes.
BCBSAZ staff members who were not involved in the initial determination will review
the grievance, including any new information submitted to BCBSAZ. The provider submitting
the grievance will be notified in writing of BCBSAZ’s decision within 30 days of
receipt for pre-service issues and within 60 days of receipt for post-service issues.
BCBSAZ may extend the 30 or 60-day time period and will notify the provider in writing
of any time extension.
Grievance (Level 2)
If BCBSAZ’s Level 1 Grievance resolution is not satisfactory, the provider may request
a Level 2 Grievance. The Level 2 Grievance must be submitted in writing to BCBSAZ
within 60 days after receipt of the Level 1 Grievance determination. The written
grievance must state the reason for the grievance, including the reason for dissatisfaction
with the prior decision, and any additional information for review. The requestor
will then be notified of BCBSAZ’s final decision within 60 days of the date BCBSAZ
received the grievance. BCBSAZ may extend the 60-day time period. The provider will
be notified of any time extension.
Grievance Submission
Click here to view the “Provider Appeal and Grievance Quick Reference Guide” in
this section for a listing of grievance mailing addresses by type of issue.
For provider non-payment disputes, including but not limited to systemic or operational
problems, quality assurance problems or network adequacy problems unrelated to the
provider’s contract status contact:
Manager - Provider Network Relations S101
BCBSAZ
P.O. Box 13466
Phoenix, AZ 85002-3466
Telephone: (602) 864-4231
Fax: (602) 864-3141
E-mail: prvgriev@phx1.bcbsaz.com
Click here, to file a health care appeal on behalf of the
member, and to be connected to the link that describes the BCBSAZ Health Coverage
Appeals process.