![]() ![]() Participating providers should refer to their participating provider agreement and applicable provider manual for information on specific provider claim review or appeal rights. It is provided as a general resource to providers regarding the types of claim reviews and appeals that may be available for commercial and Medicaid claims. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.The following information does not apply to Medicare Advantage and HMO claims. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. ![]() Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Please note that the 180-day appeal deadline will still apply if you choose mediation services. For information about mediation, call the DOI Consumer Services Division at 302.674.7300 or 800.282.8611, email them at or visit the DOI office Monday through Friday, 8:00 AM - 4:30 PM at: 841 Silver Lake Boulevard, Dover, Delaware, 19904. MEDIATION SERVICES AVAILABLE: The Delaware Department of Insurance (DOI) provides free, informal mediation services that are in addition to, but do not replace, your right to a review. PLEASE NOTE: If your health plan is subject to the Employee Retirement Income Security Act (ERISA), you have the right to file a civil action under Section 502 (A) of ERISA when you have completed the Highmark Delaware appeal process. Upon request and free of charge, Highmark Delaware will provide copies of all records relevant to the claim decision. Post-service decision: For appeals relating to a Highmark Delaware denial of coverage for a service you have already received, you will be notified of the decision within 30 to 60 days.You may request an expedited appeal for a denial relating to an emergency or a life-threatening illness we will notify you and your provider within 72 hours of our decision. ![]()
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