How to Appeal a Claim Decision

If you disagree with a claim determination you can contact Blue Cross Blue Shield of Massachusetts in writing to formally request an appeal. Your appeal request must be submitted to Blue Cross Blue Shield of Massachusetts within 180 days after you receive the claim denial.

Please note that the 180-day appeal deadline will be tolled for up to one year during the COVID-19 pandemic.  The tolling period will end on the earlier of:

  • one year from the date the 180-day deadline would have begun running, or
  • 60 days after the announced end of the National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak.

A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination. Blue Cross Blue Shield of Massachusetts may consult with, or seek the participation of, medical experts as part of the appeal resolution process. By filing an appeal, you consent to this referral and the sharing of pertinent health claim information. Upon request and free of charge you have the right to reasonable access to and copies of, all documents, records, and other information relevant to your claim for benefits.

If your circumstance warrants an expedited appeals procedure, then you should contact Blue Cross Blue Shield of Massachusetts immediately. You will be asked to explain, in writing, why you believe the claim should have been processed differently and to provide any additional material or information necessary to support the claim.

Pre-Service and Post-Service Claim Appeals

You will be provided with written or electronic notification of the decision on your appeal as follows:

  • For appeals of Pre-Service Claims, the appeal will be conducted, and you will be notified by Blue Cross Blue Shield of Massachusetts of the decision within 15 days from receipt of a request for appeal.
  • For appeals of Post-Service Claims, the appeal will be conducted, and you will be notified by Blue Cross Blue Shield of Massachusetts of the decision within 30 days from receipt of a request for appeal.
  • For appeals of Concurrent Care Claims, the appeal will be conducted, and you will be notified by Blue Cross Blue Shield of Massachusetts of the decision before treatment ends or is reduced, or within 24 hours from receipt of a request for appeal if the claim is a request for extension involving urgent care.

Urgent Care Claim Appeals

Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain. In these urgent situations:

  • The appeal does not need to be submitted in writing. You or your doctor should call Blue Cross Blue Shield of Massachusetts as soon as possible.
  • Blue Cross Blue Shield of Massachusetts will provide you with a written or electronic determination as soon as possible, but not later than 72 hours following receipt of your request for review of the determination.