Use the Correct Form for Faster Appeal Response

We’ve recently noticed numerous appeals are being sent to the wrong LifeWise address or the wrong form for the member’s plan. When submitting an appeal on behalf of a member, make sure to use the correct form to get the fastest response. You can choose from one of the following appeal forms that corresponds with the member’s plan:

Appeal Forms
LifeWise individual plan

LifeWise group plans (Clark County)

For Premera Blue Cross plans, you’ll find appeal forms on the Premera website.

Please take a moment to double-check any forms you may have bookmarked and make sure you’re sending us the right appeal form for the member’s plan.

Providers can submit an appeal for the following reasons:

• Clinical edit disagreements (include supporting documentation that shows correct billing)
• Medical necessity denials (provider write-offs)
• Allowed amounts that disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials
• Claims denied for timely filing

Please don’t submit appeals for:

• Billing errors
• Duplicate or eligibility denials
• Corrected claims
• Claims denied for needing medical records, incident questionnaires, or other additional processing information
• Coverage denials like coordination of benefits, worker’s comp, or subrogation

Appeal forms and more are located on our provider website Forms page. Be sure to bookmark our forms page for all the latest forms.