Anthem Blue Cross Blue Shield

Appeal Deadlines

Commercial: 180 days from denial date

Medicare: 60 days for Medicare Advantage

Key Facts

• +Anthem operates as Blue Cross Blue Shield in multiple states. Policies, appeal addresses, and procedures vary significantly by state. The national template does not apply uniformly.
• +Anthem was rated by 59% of physicians as having high or extremely high prior authorization burden.
• +Anthem's ACA marketplace denial rate of 23% is above the industry average of 19%.
• +Anthem uses InterQual clinical criteria for many prior authorization and medical necessity determinations.

What to Watch

• +Always verify which Anthem or BCBS entity covers your plan. Anthem Blue Cross in California is a different company from Anthem Blue Cross Blue Shield in Ohio, with different policies and appeal addresses.
• +Anthem's prior authorization requirements and covered services vary by state mandate. A service covered in one state may not be covered in another.

Appeal Tips

1. Identify the specific Anthem entity on your insurance card before filing an appeal. The appeal address and process differ by state.
2. Reference InterQual criteria in your appeal if your denial cited medical necessity. Your physician may be familiar with these criteria.
3. For state-regulated plans, check whether your state has a coverage mandate for the denied service. State mandates override plan exclusions.

Resources

• Anthem Member Appeals
• Find Your State BCBS Plan