Skip to main content

Perceived Denials

We appreciate and support your efforts to manage your BlueShield of Northeastern New York Medicare Advantage patients’ care in a prudent, cost-effective manner.

The Centers for Medicare & Medicaid Services (CMS) requires that members who perceive denial of treatment or care are entitled to certain appeal rights under federal law. This includes situations in which the member’s request is made directly to the provider and one of the following conditions exists:

  • The member disagrees with the prescribed course/type of treatment
  • The provider declines to render a course/type of treatment that the member is requesting
  • The member does not agree with the provider’s decision to discontinue or reduce a course of treatment

Examples of perceived denials:

  • A patient asks to be referred to a radiologist for an MRI, but the provider does not believe that an MRI is necessary
  • A patient asks to be referred to a dermatologist for the treatment of a rash, but the provider declines to refer the patient because they believe they can effectively treat the patient themselves
  • A patient is receiving physical therapy services and the provider determines that physical therapy is no longer necessary

Your responsibility:

When a perceived denial occurs, you must:

  • Contact our Utilization Management Department the day the denial occurs to inform us
  • Ensure our members are informed of their right to appeal

Our responsibility:

We will issue a letter with details of the denial, including description and reason for the denial. A copy of the letter will be sent to you as well. The letter will inform the member of:

  • Clinical rationale
  • Their right to obtain reconsideration
  • Procedure for requesting reconsideration

The member will be advised that they can appeal if they do not agree with our decision.

If you have questions about perceived denials, please contact Utilization Management at (518) 220-4650 or 1-800-422-7333.

Working with Us

Additional Resources

We want to hear from you! Have a topic request for the next Blue Bulletin? Email us

Stay in Touch! Sign up to receive emails for provider news and information