August 2009
Regence's Adverse Determination Appeal Process
The Regence Provider Billing Dispute and Medical Necessity/Investigational Procedure Determination Appeal Process (Adverse Determination Appeal Process) applies only when a provider is at financial risk for the cost of a claim.
Two types of claim denials are included in the Adverse Determination Appeal Process:
- Billing disputes or coding edits
- Medical necessity/investigational
Appeals for hospital claims follow the process outlined in the hospital's current agreement with Regence BlueShield. The Regence Member Appeal Process applies when a member is or may be at financial risk for the cost of the claim.
Learn more about our Adverse Determination Appeal Process.