How do I submit a reconsideration or appeal by payer?
Quick Answer
The submission method depends on the payer and product. UHC and Regence now rely heavily on electronic portal submission, Humana and Aetna support Availity workflows, Premera currently uses provider appeal forms with fax/mail while its Availity rollout is delayed, Medicare uses the responsible MAC, and TRICARE claim appeals have region-specific fax/mail routes.
Step-by-Step Instructions
Identify the exact payer and product
Do not stop at “BCBS,” “Medicare,” or “Medicaid.” Identify the specific plan, network, member product, and whether it is commercial, Medicare Advantage, Medicaid managed care, FEP, BlueCard, or Original Medicare.
Check whether the payer requires reconsideration first
UnitedHealthcare generally uses a reconsideration-before-appeal sequence for claim-payment disputes. Other payers use different terms and may allow direct appeal depending on the issue.
Use the payer portal when required or available
UHC uses its Provider Portal for most reconsiderations and post-service appeals. Regence requires most provider appeals through Availity Essentials. Humana finalized-claim disputes and Aetna disputes/appeals can also be submitted through Availity.
Use fax/mail only when that payer workflow calls for it
Premera currently directs provider appeals through the correct appeal form and fax/mail while its Availity appeal rollout remains delayed. TRICARE West and East also publish region-specific fax/mail appeal routes.
For Medicare, find the correct MAC
Original Medicare first-level appeals are redeterminations filed with the Medicare Administrative Contractor that processed the claim. Most MACs offer secure portal submission, but fax/mail details are MAC-specific.
For Medicaid and Blue plans, avoid assuming one universal process
Medicaid managed-care plans and independent Blue Cross Blue Shield plans have plan-specific appeal routes. Follow the responsible plan’s current provider instructions and the denial notice.
Save proof of every submission
Keep the portal confirmation, appeal ID, fax confirmation, uploaded-document list, or mailing proof. Document the submission date and follow-up timeframe in the account note.
Common Mistakes to Avoid
Using a fax number from the wrong payer product or Blue plan.
Mailing an appeal when the payer requires electronic submission.
Uploading an appeal as a generic claim attachment when the payer has a dedicated appeal tool.
Calling something an appeal when it is actually a corrected claim or COB update.
Failing to save the portal or fax confirmation.
Using old bookmarked payer instructions without checking the current provider site.