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62 11/2005
Provider Complaint and Appeal Decisions
The Practitioner/Provider complaint and appeal process establishes the structure and
processes by which BCBSGa participating physicians can pursue resolution for issues
related to administrative and contractual, determinations. The policies define how
these issues will be investigated and resolved. If a practitioner/provider does not
dispute or question a specific payment within 365 days of receipt of payment, they
shall be deemed to have waived all rights to dispute said payment.
For all network practitioners and providers, we offer a formal process to handle
complaints about:
• Administrative procedures and processes, such as claims payments,
reimbursements, lack of pre-authorization, etc.
• Contractual disputes, such as timeliness of filing or contract language
interpretation.
All network physicians have the opportunity to appeal initial determinations made by
BCBSGa. These issues are unrelated to utilization management complaints and
appeals. For information about the utilization management complaint and appeals
process, please see the utilization management section of the manual.
Inquiry
A practitioner or provider may voice his or her concern or dissatisfaction with an issue
by calling Customer Service at 1-800-241-7475, from 7 AM to 7 PM weekdays. A
customer service representative will communicate a response to the provider, either
verbally or in writing.
Complaint
If the provider remains dissatisfied after receiving the initial decision, he or she may
initiate a complaint by sending documentation, including a cover letter outlining the
issue. If the complaint is 10 pages or fewer, the complaint can be faxed to 1-877-
868-7950. For longer documents, the provider can mail to: