Grievance Program

Grievance Program

 

You have the right to a full and fair review when you disagree with a decision that is made by Blue Cross and Blue Shield to deny coverage or payment for services; or you disagree with how your claim was paid; or you have a complaint about the care or service you received from Blue Cross and Blue Shield or from a health care provider who participates in your health care network; or you are denied coverage in this health plan or your coverage is cancelled or discontinued by Blue Cross and Blue Shield for reasons other than nonpayment of your cost for coverage in this group health plan.

Inquiries and/or Claim Problems or Concerns

Most problems or concerns can be handled with just one phone call. For help to resolve a problem or concern, you should first call the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. A customer service representative will work with you to help you understand your coverage or to resolve your problem or concern as quickly as possible.

When resolving a problem or concern, Blue Cross and Blue Shield will consider all aspects of the particular case. This includes looking at: all of the provisions of this health plan; the policies and procedures that support this health plan; the health care provider’s input; and your understanding and expectation of coverage by this health plan. Blue Cross and Blue Shield will use every opportunity to be reasonable in finding a solution that makes sense for all parties. Blue Cross and Blue Shield may use an individual consideration approach when it is judged to be appropriate. Blue Cross and Blue Shield will follow its standard guidelines when it resolves your problem or concern.

If after speaking with a Blue Cross and Blue Shield customer service representative, you still disagree with a decision that is given to you, you may request a review through the Blue Cross and Blue Shield internal formal grievance program.

Formal Grievance Review

Internal Formal Grievance Review

How to Request a Grievance Review
To request a formal review from the Blue Cross and Blue Shield internal Member Grievance Program, you (or your authorized representative) have three options.

  • Write or Fax. The preferred option is for you to send your grievance in writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Or, you may fax your grievance to 1-617-246-3616. Blue Cross and Blue Shield will let you know that your request was received by sending you a written confirmation within 15 calendar days.
  • E-mail. Or, you may send your grievance to the Blue Cross and Blue Shield Member Grievance Program internet address grievances@bcbsma.com. Blue Cross and Blue Shield will let you know that your request was received by sending you a confirmation immediately by e-mail.
  • Telephone Call. Or, you may call the Blue Cross and Blue Shield Member Grievance Program at 1-800-472-2689.

Once your request is received, Blue Cross and Blue Shield will research the case in detail. They will ask for more information if it is needed. Blue Cross and Blue Shield will let you know in writing of the decision or the outcome of the review. If your grievance is about termination of your coverage for concurrent services that were previously approved by Blue Cross and Blue Shield, the disputed coverage will continue until this grievance review process is completed. This continuation of your coverage does not apply to: services that are limited by a dollar or visit maximum and that exceed that benefit limit; non-covered services; or services that were received prior to the time that you requested a formal grievance review; or when a grievance is not received on a timely basis, based on the course of treatment.

All grievances must be received by Blue Cross and Blue Shield within one year of the date of treatment, event, or circumstance, such as the date you were told of the service denial or claim denial.

What to Include in a Grievance Review Request
Your request for a formal grievance review should include: the name, ID number, and daytime phone number of the member asking for the review; a description of the problem; all relevant dates; names of health care providers or administrative staff involved; and details of the attempt that has been made to resolve the problem. If Blue Cross and Blue Shield needs to review the medical records and treatment information that relate to your grievance, Blue Cross and Blue Shield will promptly send you an authorization form to sign if needed. You must return this signed form to Blue Cross and Blue Shield. It will allow for the release of your medical records. You also have the right to look at and get copies (free of charge) of records and criteria that Blue Cross and Blue Shield has and that are relevant to your grievance, including the identity of any experts who were consulted.

Authorized Representative
You may choose to have another person act on your behalf during the grievance review process. You must designate this person in writing to Blue Cross and Blue Shield. Or, if you are not able to do this, a person such as a conservator, a person with power of attorney, or a family member may be your authorized representative. Or, he or she may appoint another party to be the authorized representative. (When you are an inpatient, a health care provider may act as your authorized representative to ask for an expedited grievance review. In this case, you do not have to designate the health care provider in writing.)

Who Handles the Grievance Review
All grievances are reviewed by professionals who are knowledgeable about Blue Cross and Blue Shield and the issues involved in the grievance. The professionals who will review your grievance will be those who did not participate in any of Blue Cross and Blue Shield’s prior decisions regarding the subject of your grievance, nor do they work for anyone who did. When a grievance is related to a medical necessity denial, at least one grievance reviewer is an individual who is an actively practicing health care professional in the same or similar specialty who usually treats the medical condition or performs the procedure or provides treatment that is the subject of your grievance.

Response Time
The review and response for Blue Cross and Blue Shield’s internal formal grievance review will be completed within 30 calendar days. Every reasonable effort will be made to speed up the review of grievances that involve health care services that are soon to be obtained by the member. With your permission, Blue Cross and Blue Shield may extend the 30-calendar-day time frame to complete a grievance review. This will happen in those cases when Blue Cross and Blue Shield and the member agree that additional time is required to fully investigate and respond to the grievance.

Blue Cross and Blue Shield may also extend the 30-calendar-day time frame when the grievance review requires a review of your medical records and Blue Cross and Blue Shield requires your authorization to get these records. The 30-day response time will not include the days from when Blue Cross and Blue Shield sends you the authorization form to sign until it receives your signed authorization form (if needed). If Blue Cross and Blue Shield does not receive your authorization within 30 working days after your grievance is received, Blue Cross and Blue Shield may make a final decision about your grievance without that medical information. In any case, for a grievance review involving services that have not yet been obtained by you, Blue Cross and Blue Shield will ask for your permission to extend the 30-day time frame if it cannot complete the review within 30 calendar days of receipt of your grievance.

Important Note: If your grievance review began after an inquiry, the 30-day response time will begin on the day you tell Blue Cross and Blue Shield that you disagree with Blue Cross and Blue Shield’s answer and would like a formal grievance review.

Written Response
Once the grievance review is completed, Blue Cross and Blue Shield will let you know in writing of the decision or the outcome of the review. If Blue Cross and Blue Shield continues to deny coverage for all or part of a health care service or supply, Blue Cross and Blue Shield will send an explanation to you. This notice will include: information related to the details of your grievance; the reasons that Blue Cross and Blue Shield has denied the request and the applicable terms of your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross and Blue Shield has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross and Blue Shield clinical guidelines that apply and were used and any review criteria; and how to request an external review.

Grievance Records
You have the right to look at and get copies of records and criteria that Blue Cross and Blue Shield has nd that are relevant to your grievance. These copies will be free of charge. Blue Cross and Blue Shield will maintain a record of all formal grievances, including the response for each grievance review, for up to seven years.

Expedited Review for Immediate or Urgently-Needed Services
In place of the formal grievance review described above, you have the right to request an “expedited” review right away when your grievance review concerns medical care or treatment for which waiting for a response under the grievance review time frames described above would seriously jeopardize your life or health or your ability to regain maximum function as determined by Blue Cross and Blue Shield or your physician, or if your physician says that you will have severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance review. If you request an expedited review, Blue Cross and Blue Shield will review your grievance and notify you of the decision within 72 hours after your request is received, or such shorter time period as required by federal law.

External Grievance Review

You must first go through the Blue Cross and Blue Shield internal formal grievance process as described above. The Blue Cross and Blue Shield internal grievance review decision may be to continue to deny allor part of your coverage in this health plan. In this case, you may be entitled to a voluntary external grievance review. You are not required to pursue an external grievance review. Your decision whether to pursue an external grievance review will not affect your other coverage. If you receive a grievance denial letter from Blue Cross and Blue Shield in response to your internal grievance review, the letter will tell you what steps you can take to file a request for an external grievance review. If you decide to request an external grievance review, you must file your request within the four months after you receive the denial letter from Blue Cross and Blue Shield. Blue Cross and Blue Shield will work closely with you to guide you through the external grievance review process.

You (or your authorized representative) have the right to file an “expedited” external grievance review at the same time that you file a request for an internal expedited grievance review. This right applies to a member who is in an urgent care situation or to a member receiving an ongoing course of treatment. See below for more information about requesting an expedited external grievance review.

How to Request an External Review
To request an external review, you must complete the external review request form that is provided with the grievance denial letter you receive from Blue Cross and Blue Shield. Once your external review request form is completed, you must send it to Blue Cross and Blue Shield as shown on the form.

You (or your authorized representative) have the right to request an expedited external review when your situation is for immediate or urgently-needed services as follows:

  • When your grievance concerns medical care or treatment for which waiting for a response under the standard (non-expedited) external grievance review time frames would seriously jeopardize your life or health or your ability to regain maximum function; or
  • When your grievance concerns an internal grievance review final adverse benefit determination for an admission, availability of care, continued stay, or health care services for which you received emergency services, while you are an inpatient.

External Review Process
When Blue Cross and Blue Shield receives your request for an external review, your case will be referred to an external review agency to complete your external review. You (or your authorized representative) will be notified by the external review agency of your eligibility and acceptance for an external review. In some cases, the review agency may need more information about your grievance. If this is the case, they will request it from Blue Cross and Blue Shield, you, or your authorized representative.

The review agency will consider all aspects of the case and send a written response of the outcome. They will send the response to you (or your authorized representative) and to Blue Cross and Blue Shield within 45 days of receiving the request. If the agency determines additional time is needed to fully and fairly evaluate the request, the agency will notify you and Blue Cross and Blue Shield of the extended review period. In the case of an expedited review, you will be notified of their decision within 72 hours. This 72-hour period starts when the external review agency receives your case.

If the review agency overturns Blue Cross and Blue Shield’s decision in whole or in part, Blue Cross and Blue Shield will send you (or your authorized representative) a notice of the review decision made by the agency. This notice will confirm the decision of the review agency. It will also tell you (a) what steps or procedures you must take (if any) to obtain the requested coverage or services; (b) the date by which Blue Cross and Blue Shield will pay for or authorize the requested services; and (c) the name and phone number of the person at Blue Cross and Blue Shield who will make sure your grievance is resolved.

The decision made by way of the external review process will be accepted as final.

You have the right to look at and get copies of records and criteria that Blue Cross and Blue Shield has and that are relevant to your grievance. These copies will be free of charge.

Appeals Process for Rhode Island Residents or Services

You may also have the right to appeal as described in this section when your claim is denied as being not medically necessary for you. If so, these rights are in addition to the other rights to appeal that you have as described in other parts of this benefit booklet. The following provisions apply only to:

  • A member who lives in Rhode Island and that member is planning to obtain services which Blue Cross and Blue Shield has determined are not medically necessary.
  • A member who lives outside of Rhode Island and that member is planning to obtain services in Rhode Island which Blue Cross and Blue Shield has determined are not medically necessary.

Blue Cross and Blue Shield decides which covered services are medically necessary for you by using its medical necessity guidelines. Some of the services that are described in this benefit booklet may not be medically necessary for you. If Blue Cross and Blue Shield has determined that a service is not medically necessary for you, you have the right to the following appeals process:

Reconsideration
A reconsideration is the first step in this process. If you receive a letter from Blue Cross and Blue Shield that denies payment for your health care services, you may ask that Blue Cross and Blue Shield reconsider its decision. You must do this by writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. You must send your request within 180 days of Blue Cross and Blue Shield’s adverse decision. Along with your letter, you should include any information that will support your request. Blue Cross and Blue Shield will review your request. Blue Cross and Blue Shield will let you know the outcome of your request within 15 calendar days after it has received all information needed for the review.

Appeal
An appeal is the second step in this process. If Blue Cross and Blue Shield continues to deny coverage for all or part of the original service, you may request an appeal. You must do this within 60 days of the date that you receive the reconsideration denial letter from Blue Cross and Blue Shield. Your appeal request should include any information that supports your appeal. You may also inspect and add information to your Blue Cross and Blue Shield case file to prepare your appeal. In accordance with Rhode Island state law, if you wish to review the information in your Blue Cross and Blue Shield case file, you must make your request in writing and you must include the name of a physician who may review your case file on your behalf. Your physician may review, interpret, and disclose any or all of that information to you. Once received by Blue Cross and Blue Shield, your appeal will be reviewed by a health care provider in the same specialty as your attending provider. Blue Cross and Blue Shield will notify you of the outcome of your appeal within 15 calendar days after it has received all information needed for the appeal.

External Appeal
If your appeal is denied, you have the right to present your case to an appeals agency that is designated by Rhode Island and not affiliated with Blue Cross and Blue Shield. If you request this voluntary external appeal, Rhode Island requires that you pay for half of the cost of the appeal. Your group will pay for the remaining half. The notice you receive from Blue Cross and Blue Shield about your appeal will advise you of: the name of the appeals agency that is designated by Rhode Island; and your share of the cost for an external appeal. To file an external appeal, you must make your request in writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Along with your request, you must: state your reason(s) for your disagreement with Blue Cross and Blue Shield’s decision; and enclose a check made payable to the designated appeals agency for your share of the cost for the external appeal.

Within five working days after Blue Cross and Blue Shield receives your written request and payment for the appeal, Blue Cross and Blue Shield will forward your request to the external appeals agency. Blue Cross and Blue Shield will also send your group’s portion of the fee and your entire Blue Cross and Blue Shield case file. The external appeals agency will notify you in writing of the decision within ten working days of receiving all necessary information.

Expedited Appeal
If your situation is an emergency, you have the right to an “expedited” appeal at all three levels of appeal as stated above. An emergency is defined as the sudden onset of a medical or mental condition that in the absence of immediate medical attention could reasonably be expected to result in placing your health or your ability to regain maximum function in serious jeopardy or, in your physician’s opinion, would result in severe pain. You may request an expedited reconsideration or appeal by calling Blue Cross and Blue Shield at the phone number shown in your letter. Blue Cross and Blue Shield will notify you of the result of your expedited appeal within two working days or 72 hours of its receipt, whichever is sooner, or such shorter time period as required by federal law. If your appeal is denied, you have the right to request an expedited external appeal. The notice you receive from Blue Cross and Blue Shield about your appeal will advise you of: the name of the appeals agency that is designated by Rhode Island; and the amount that Rhode Island requires you pay for your share of the cost for an expedited external appeal. To request an expedited external appeal, you must send your request in writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Your request should state your reason(s) for your disagreement with the decision and include signed documentation from your provider that describes the emergency nature of your treatment. In addition, you must also enclose a check made payable to the designated appeals agency for your share of the cost for the expedited external appeal.

Within two working days after the receipt of your written request and payment for the appeal, Blue Cross and Blue Shield will forward your request to the external appeals agency along with your group’s portion of the fee and your entire Blue Cross and Blue Shield case file. The external appeals agency will notify you in writing of the decision within two working days or 72 hours, whichever is sooner, of receiving your request for a review.

External Appeal Final Decision
If the external appeals agency upholds the original decision of Blue Cross and Blue Shield, this completes the appeals process for your case. But, if the external appeals agency reverses Blue Cross and Blue Shield’s decision, the claim in dispute will be reprocessed by Blue Cross and Blue Shield upon receipt of the notice of the final appeal decision. In addition, Blue Cross and Blue Shield will repay you for your share of the cost for the external appeal within 60 days of the receipt of the notice of the final appeal decision.