Statement of overpayment recoveries
A Statement of Overpayment Recoveries (SORA) is included with an Explanation of Payment (EOP) when we've processed an overpayment recovery activity within a payment cycle. The SORA is generated when one of the following occurs during a payment cycle:
- An amount is deducted from your check.
- An overpayment was recorded during the payment cycle.
- There is a balance due to us at the end of the payment cycle.
- Money was posted to your account during the payment cycle.
- There is other activity on your account during the payment cycle.
Provider appeals
Physicians and providers have the right to appeal certain actions of ours. Our provider complaints and appeals process ensure we address a complaint or an appeal in a fair and timely manner. Our process meets or exceeds the requirements set by the Office of the Insurance Commissioner.
The provider appeals process does not apply to FEP, BlueCard Home Claims, Medicare Supplement plans, or Medicare Advantage plans.
Complaints
You can submit a complaint about one of our actions (verbally or in writing) to one of our employees. You have 365 calendar days to submit a complaint following the action that prompted the complaint. Complaints received beyond the 365-day timeframe will not be reviewed and the appeals rights pertaining to the issue will be exhausted.
If we receive the complaint before the 365-day deadline, we review and issue a decision within 30 calendar days via letter or revised Explanation of Payment.
You can make a complaint verbally to Customer Service or in writing to Customer Service Correspondence. You can reach Customer Service by calling 877-342-5258, option 2. The plan mailing addresses are available on our website under Contact Us.
Level I appeal
A Level I Appeal is used to dispute one of our actions.
The Level I Appeal must be submitted within 365-days following the action that prompted the dispute. Only appeals received within this period will be accepted for review. Appeals rights will be exhausted if not received within the required timeframe.
Modifications we make to your contract or to our policy or procedures are not subject to the appeal process unless we made it in violation of your contract or the law.
A Level I Appeal is used for both billing and non-billing issues. A billing issue is classified as a provider appeal because the issue directly impacts your write-off or payment amount. A non-billing issue is classified as a member appeal because the financial liability is that of the member, not the provider (please refer to Chapter 6). Here are examples:
| Billing Examples | Non-Billing Examples |
|---|---|
| Multiple Modifier Reimbursem*nt | Service not a benefit of subscriber's contract |
| Bundling or Inclusive Procedures | Investigational or experimental procedure |
A Level I Appeal must be submitted with complete supporting documentation that includes all of the following:
- A detailed description of the disputed issue
- Your position on the disputed issue
- All evidence offered by you in support of your position including medical records
- A description of the resolution you are requesting
Incomplete appeal submissions are returned to the sender with a letter requesting information for review. The time period does not start until we receive a complete appeal. Once the submission is complete and if the issue is billing related, we review the request and issue a decision within 30 days, along with your right to submit a Level II Appeal if you are not satisfied with the outcome. Only a member can request a Level I or Level II Appeal for a non-billing issue, unless the member has completed a release to allow the provider to act as their Representative.
Level II appeal
Level II appeals must be submitted in writing within 30 calendar days of the Level I appeal decision and can only pertain to a billing issue. If the Level II appeal is timely and complete, the appeal will be reviewed. We notify you in writing if the Level II appeal is not timely and your appeal rights will be exhausted. Once we accept your level II appeal, we will respond within 15 days in writing or a revised Explanation of Payment. We also provide information regarding mediation should you disagree with the decision.
Mediation
You must request mediation in writing within 30 days after receiving the Level II appeals decision on a billing dispute. We notify you in writing if the request for mediation is not timely. If your request for mediation is timely, both parties must agree upon a mediator. The mediator consults with the parties, determines a process, and schedules the mediation. If we cannot resolve the matter through non-binding mediation, either one of us may institute an action in any Superior Court of competent jurisdiction. The mediator's fees are shared equally between the parties. All other related costs incurred by the parties shall be the responsibility of whoever incurred the cost.
Submitting an appeal
To submit a Level I, Level II or Mediation Appeal (see above to submit a Complaint), send complete documentation to:
Physician and Provider Appeals
P.O. Box 91102
Seattle, WA 98111-9202
