Medicaid Provider Dispute Process Overview

If you provide care and services to our members with Blue Cross Community Health PlansSM, review this information on how to submit claim disputes to Blue Cross and Blue Shield of Illinois.

Claim dispute and complaint process

When you bill for services rendered to members with BCCHPSM, your claim is sent to our claims department for processing. After processing, the claim will be paid, partially denied or denied. If you feel the claim was incorrectly paid or denied, you can file a claim dispute. BCBSIL gives network and non-network providers at least 60 days to dispute a claim after BCBSIL has partially paid or denied it. You may also dispute a recovery request initiated by BCBSIL via this process if you believe the associated claim adjustment was incorrect.

If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected/replacement claim instead of a claims dispute.

All provider correspondence related to claim disputes requires inclusion of a valid Managed Care Organization reference number, or unique tracking identifier, for BCCHP.

How to file a claims dispute and obtain unique tracking ID

Follow the instructions below to submit your request. Be sure to use the correct phone or fax number.

Call customer service:

  • File the dispute by calling Customer Service at 877-860-2837 (BCCHP)
  • You must indicate that you want to file a claims dispute
  • The customer service representative will give you a reference number, or unique tracking ID, which can be used to track the dispute.

Fax or mail a request form:

  • Complete the Provider Claims Inquiry or Dispute Form for BCCHP 
  • Include all requested information on the form
  • Fax or mail the form to the contact information on the form
  • For status updates, call customer service and ask for a reference number, or unique tracking ID, for your dispute. Allow 7-10 business days before requesting this number.

Unique tracking ID format and use

All claim disputes for BCBSIL are assigned a unique tracking ID number. The unique tracking ID for BCCHP has 9 digits and will appear in the following format: 123456789.

Healthcare and Family Services Provider Complaint Portal: For more information on the use of the reference number, or unique tracking ID, in relation to the HFS Provider Complaint Portal, refer to the HFS website. The reference number, or unique tracking ID, must be used to submit any complaints regarding claims to the HFS portal. This process must be followed for the issue to be accepted by HFS. Submission of any other ticket type to the HFS portal isn't appropriate.

Response to a submitted claims dispute

Upon completion of its review, BCBSIL will send a response letter to the submitter detailing the results of the review. The letter will specify if the claim outcome was upheld or overturned along with a reason for this outcome and the related reference number or unique tracking ID.

Your dispute may be rejected if it:

  • Is a duplicate to an existing claim dispute
  • Wasn’t submitted within the allowable timeframe (60 days) to submit a dispute

Refer to the provider manual for a sample of the claims dispute outcome letter.

If the dispute isn’t resolved to your satisfaction, you may contact your Provider Network Consultant. If your claim is adjusted as part of the dispute process, you’ll also receive an Electronic Remittance Advice as you would for any claim processed.

Other requests

Claims inquiries: Submit claims inquiries to Customer Service for BCBSIL by calling 877-860-2837, or by fax or mail using the Provider Claims Inquiry or Dispute Form. Claims inquiries don't result in a claim outcome review and are intended to address a claim status question, such as denial reason clarification or reissue of a check.

Service authorization disputes: Use the Medicaid Service Authorization Dispute Resolution Request Form to file a written preservice authorization dispute resolution request related to an adverse determination for members with BCCHP.

  • Service authorization disputes include non-claims scenarios, such as authorization denial, or a reduction, suspension or termination of a previously authorized service.
  • If you failed to request a prior authorization before service delivery, this process isn’t for retrospective medical necessity review.

For more detail on the difference between a claims dispute and a service authorization dispute please refer to the provider manual.

Appeals

The appeal process for BCBSIL is used for services that require an authorization, and the request has been denied.

If you have any questions, contact Customer Service for BCCHP at 877-860-2837.