Blue Cross Blue Shield (BCBS)

Blue Cross Blue Shield is a federation of 34 independent, locally operated companies providing health insurance. Each BCBS company has its own formulary and prior authorization criteria, which means coverage can vary significantly by state and plan. BCBS collectively covers more Americans than any other insurer.

Common Denial Patterns

• •Local plan criteria not met — each BCBS company has different coverage policies
• •Step therapy varies by state — what one BCBS plan requires, another may not
• •Preferred product list requirements — BCBS plans may have different preferred biologics
• •Medical policy inconsistency across BCBS affiliates
• •Out-of-network provider performing the service

Step Therapy Approach

Step therapy requirements vary by BCBS affiliate. Some plans follow national BCBS Association medical policies while others develop local criteria. Always identify the specific BCBS affiliate (e.g., BCBS of Texas, Horizon BCBS NJ, Empire BCBS) to understand which step therapy applies.

Appeal Process

Appeal processes vary by BCBS affiliate. Generally, internal appeals must be filed within 180 days. Each affiliate has its own appeal forms and submission process. External review is available in all states. Contact the specific BCBS plan for their appeal procedures.

Tips for Appealing Blue Cross Blue Shield (BCBS) Denials

1. 1.Identify your specific BCBS affiliate — there are 34 separate companies with different policies
2. 2.Check the BCBS Association's Evidence Street for national medical policy references
3. 3.Document everything against the specific BCBS affiliate's medical policy, not a generic BCBS policy
4. 4.Some BCBS plans participate in shared prior authorization systems — ask if prior approvals transfer
5. 5.For employer-sponsored plans, the employer's benefit design may override standard BCBS formulary