Appeals and Grievances for Providers

a.) Terminations for professional competency, conduct or quality of care.

Contracted providers may dispute BCBSAZ's decision to terminate a contract for lack of professional competence or for professional misconduct.

Examples of these diputes include, but are not limited to:

• Belief that a quality of care issues exists
• Adverse action taken by a hospital
• Disciplinary action taken by a licensing board
• Trend or pattern of quality of care issues

If a provider is terminated for professional competency and/or conduct:

• The provider will be notified in writing of the reason for the termination
• The provider may request reconsideration in writing not later than 30 calendar days after receipt of notice of termination from BCBSAZ.
• The BCBSAZ Credentials Committee, consisting of at least 3 qualified individuals with at least one participating clinical peer provider, will consider the reconsideration request.
• The Committee will notify the provider within 10 business days of its decision.
• If the provider is not satisfied with the committee decision, a second level appeal may be requested not later than 30 calendar days of the receipt of the committee decision.
• A panel of three individuals who did not participate in the first level decision, including at least one participating provider who is a clinical peer of the appealing provider, will consider the second level appeal.
• The panel's decision is final and will be communicated to the provider in writing, via certified mail, within 10 business days of the decision.

b.) Immediate Suspension or Termination related to concerns for Consumer Safety

If a BCBSAZ Medical Director believes a provider is practicing in a manner that poses a significant risk to the health, welfare, or safety of consumers, BCBSAZ and either immediately suspend or terminate the provider.

• If the circumstances require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately suspend the provider contract and conduct an expedited investigation.
• If the circumstances do not require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately terminate the provider contract.
• Examples of circumstances that might result in immediate suspension or termination include, but are not limited to:
     - Insufficient or no professional liability insurance
     - Sanction by Medicare/Medicaid
     - Exclusion from any Federal Programs
     - A change in license status
     - Fraudulent activity
  

When a suspension or termination occurs:

• The provider is immediately removed from the provider directory.
• The provider is notified of the suspension or termination in writing. The notification will include the reason for the suspension or termination.
• The provider may request reconsideration in writing not later than 30 calendar days after receipt of notice of termination from BCBSAZ.
• The BCBSAZ Credentials Committee, consisting of at least 3 qualified individuals with at least one participating provider who is a clinical peer, will consider the reconsideration request.
• The Committee will notify the provider within 10 business days of the decision.
• If the provider is not satisfied with the committee decision, a second level appeal may be requested not later than 30 calendar days of the receipt of the Committee decision.
• A panel of three individuals who did not participate in the first level decision, including at least one participating provider who is a clinical peer, will consider the second level appeal.
• The panel's decision is final and will be communicated to the provider in writing, via certified mail, within 10 business days.

II. DISPUTE RESOLUTION PROCESS FOR ADMINISTRATIVE MATTERS

Administrative Disputes

Disputes regarding administrative matters may arise when a contracted provider wishes to protest BCBSAZ's decision that the provider has breached the provider's participation agreement, or violated a BCBSAZ policy. A professional competence, conduct, or quality of care dispute is not administrative and is not handled under this procedure.

Examples of administrative disputes include, but are not limited to:

• Non-compliance with administrative terms in the participation agreement or Provider Operating Guide
• Billing the member improperly
• Failure to submit requested medical records

When an administrative dispute occurs:

• BCBSAZ will send a letter to the provider detailing the contractual breach or administrative violation.
• The provider may request a reconsideration in writing not later than 30 days after receipt of the notice from BCBSAZ.
• An authorized representative of the organization not involved in the initial decision on the subject of the dispute will consider the written reconsideration.
• The authorized representative's decision is final and will be communicated to the provider in writing within 30 calendar days.

III. DISPUTE RESOLUTION PROCESS FOR PROVIDER GRIEVANCES

This dispute resolution process is intended to satisfy the requirements of Arizona state law that BCBSAZ establish an internal system for resolving payment disputes and other contractual grievances with health care providers. It is available to contracted and noncontracted providers.

When a provider disagrees with adjudication of a claim or adjustment, or wishes to grieve a nonpayment issue, the provider may initiate the Provider Grievance Process (the "Grievance Process"), which has two levels of review.

Grievable Issues Include:

• Whether a claim was clean
• Failure to timely pay a claim
• Amount paid (bundling software)
• Amount paid (other than bundling software)
• Amount or timeliness of interest payment
• Adjustment request
• Denials that require a provider write-off (for example: investigational/experimental)
• Network adequacy (other than the provider's contract status)
• Systemic or operational problems
• COB issues
• Coinsurance/deductible and sanction deductible
• Fee schedule disputes
• Outpatient global pricing
• DRG payment
• Fragmentation of incidental procedures
• Modifiers
• Multiple medical/surgical procedure processing
• Mutually exclusive procedures
• Procedure unbundling
• Timely filing (Refer to information on Timely Filing in Section 6, pages 6-10 through 6-12)

Provider Grievance (Level 1)

All Grievances must be in writing and submitted to BCBSAZ not later than one year of the denial or other notification, or date of the occurrence if the provider did not receive notification. BCBSAZ may extend this one-year time period for good cause or if a longer period is required by state or federal law. "Good cause," as used in this section, means circumstances beyond the reasonable control of the provider, and which prevented the provider from submitting a timely grievance request.

A Level 1 Grievance request should include:

• A reference to, or copy of, the action with which the provider disagrees.
• A written explanation of why the provider thinks the action is wrong, and the relief that the provider is requesting.
• Documentation that supports the 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. (*For FEP, the provider submitting the grievance will be notified in writing of BCBSAZ's decision within 60 days of receipt.)

BCBSAZ may extend the 30 or 60-day time period for up to an additional 60 days. If BCBSAZ requires an extension, BCBSAZ will notify the provider in writing prior to the expiration of the initial time period.

BCBSAZ will mail all decisions to the provider's last address on file with BCBSAZ, except for providers located outside Arizona. BCBSAZ will transmit decisions for out-of-state providers to the Blue plan in the provider's home state, and that Blue plan will send the decision to the provider. The decision is deemed received on the date of delivery, if hand delivered, or, if mailed, on the earlier of the actual date of receipt or five days after deposit in the United States mail, postage prepaid.

Provider 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. A provider may extend the 60-day time period for up to an additional 60 days. If the provider requires this additional time to submit the Level 2 Grievance, the provider will notify BCBSAZ in writing within the initial 60-day period.

The Level 2 grievance must state the reason for dissatisfaction with the prior decision, and submit any additional information for review. BCBSAZ will notify the provider of BCBSAZ's final decision within 60 days of the date BCBSAZ receives the provider's Level 2 grievance. BCBSAZ may extend this 60-day time period for up to 30 days on written notice to the provider, given within the 60-day period.