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A How-To:
Coverage Appeals

Almost all health insurers have a specific process to appeal an unfavorable coverage decision. Bristol-Myers Squibb (BMS) Access Support can assist in navigating the appeals process. However, the preparation and submission of documents to support the appeal is the responsibility of the patient and/or healthcare provider.

Bristol-Myers Squibb and its agents make no guarantee regarding the outcome of appeals assistance.

When you’re filing an appeal, keep in mind:

  • Coverage decisions may be made by an insurer before the treatment is rendered or after a claim is filed. Coverage decisions that are made before a treatment regimen is initiated are often referred to as “prior authorization” or “coverage determinations.”1
  • Medicare Part B and many other health insurers will not make a coverage decision regarding individual patients before a claim is filed. Coverage is considered only at the time a claim is presented for payment.
  • The billing provider can usually appeal an insurer's decision to deny coverage for a claim.2 Appeals are almost always subject to timeliness requirements. The window of time allowed for a provider to appeal an unfavorable coverage decision usually begins on the date a claim was adjudicated (processed) by the insurer.3
  • If the health insurer approves an appeal, you will be notified and the claim will be reconsidered.
  • If the health insurer denies the appeal, contact BMS Access Support for further assistance at 1-800-861-0048.

Each plan has its own process and timeline for appeals. The appeals process for Medicare Part B contractors is determined by the Centers for Medicare and Medicaid Services (CMS) and is outlined below.

Medicare Appeals: Parts B and D

 

References:
1. American Academy of Actuaries. Health Insurance Coverage and Reimbursement Decisions: Implications for Increased Comparative Effectiveness Research: 2008.
2. Healthcare.gov_appeals. How do I appeal a health plan decision? https://www.healthcare.gov/how-do-i-appeal-a-health-insurance-companys-decision/. Accessed August 6, 2015.
3. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf. Accessed August 6, 2015.

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol-Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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