Dental Blue FT - Grievance Program

Grievance Program

 

You have the right to a review when you disagree with a decision by Dental Blue Freedom to deny payment for services, or if you have a complaint about the service you received from Blue Cross and Blue Shield or a dentist who has a payment agreement to furnish dental services to members.

Making an Inquiry and/or Resolving Claim Problems or Concerns

Most problems or concerns can be handled with just one phone call. For help resolving a problem or concern, you should first call the Blue Cross and Blue Shield customer service office at the toll-free telephone number shown on your Dental Blue Freedom identification card. A customer service representative will work with you to help you understand your benefits or 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, including the terms of your group benefits as described in this Dental Blue Freedom Benefit Description, Blue Cross and Blue Shield policies and procedures that support the administration of these benefits, the dentist’s input, as well as your understanding and expectation of benefits. Blue Cross and Blue Shield will use every opportunity to be reasonable in finding a solution that makes sense for all parties and may use an individual case management approach when it is judged to be appropriate.

Blue Cross and Blue Shield will follow its standard business practices guidelines when resolving your problem or concern.

If you disagree with the decision given to you by the customer service representative, you may request a review through the formal internal grievance program as described below. The formal grievance review process described below will be followed when your request for a review is because Blue Cross and Blue Shield has determined that a service or supply is not necessary and appropriate for your condition.

Formal Grievance Review

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

  • The preferred option is for you to send your grievance in writing to:
     
    Member Grievance Program
    Blue Cross and Blue Shield of Massachusetts, Inc.
    One Enterprise Drive
    Quincy, MA 02171-2126
    Fax: 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.

  • Or, you may send your grievance to the Member Grievance Program internet address at 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.
  • Or, you may call the Member Grievance Program at 1-800-462-5601 (extension 63605). When your request is made by telephone, Blue Cross and Blue Shield will send you a written account of the grievance within 48 hours of your phone call.

Once your request is received, Blue Cross and Blue Shield will research the case in detail and ask for more information as needed. When the review is completed, Blue Cross and Blue Shield will let you know in writing of the decision or the outcome of the review.

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 and Dental Blue Freedom identification 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; details of the attempt that has been made to resolve the problem; and any comments, documents, records and other information to support your grievance. If Blue Cross and Blue Shield needs to review the medical/dental 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/dental 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 may have been 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.

Who Handles the Grievance Review
All grievances are reviewed by individuals who are knowledgeable about Blue Cross and Blue Shield and the issues involved in the grievance. The individuals 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 necessity and appropriateness denial, at least one grievance reviewer is an individual who is an actively practicing health care professional in the same or similar specialty that usually treats the medical/dental condition, 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 formal internal 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. (When the grievance review is for services you have already obtained and it requires a review of your medical/dental 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 calendar days after you are asked for it, Blue Cross and Blue Shield may make a final decision about your grievance without that medical/dental information.)

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.

Blue Cross and Blue Shield may extend the time frame to complete a grievance review, with your
permission, in cases when Blue Cross and Blue Shield and the member agree that additional time is
required to fully investigate and respond to the grievance.

Response Once the grievance review is completed, Blue Cross and Blue Shield will let you know 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’s response will explain the reasons. It
will give you the specific medical and scientific reasons for the denial and a description of alternative
treatment, health care services and supplies that would be covered and information about requesting an
external review.

Grievance Records 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 timeframes 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.

External Review

For all grievances, you must first go through the formal internal grievance process as described above. In some cases, you are then entitled to a voluntary external review. Blue Cross and Blue Shield’s grievance review may deny coverage for all or part of a health care service or supply. When the denial is because Blue Cross and Blue Shield has determined that the service or supply is not necessary and appropriate, you have the right to an external review. You are not required to pursue an external review and your decision whether to pursue it will not affect your other benefits. If you receive a denial letter from Blue Cross and Blue Shield for this reason, the letter will tell you what steps you should take to file a request for an external review. A decision will be provided within ten days of the date the external reviewer receives your request for a review.

You also have the right to an expedited external review. You may request an expedited external review by contacting Blue Cross and Blue Shield at the telephone number shown in your denial letter. A final decision will be provided within 72 hours after the external reviewer receives your request for a review.

You must file your request for an external review or expedited external review within 30 days of receiving the denial letter sent to you by Blue Cross and Blue Shield following the formal internal grievance process. Blue Cross and Blue Shield will work closely with you to guide you through the external review or expedited external review process.

Appeals Process for Rhode Island Residents or Services

You may also have the right to appeal as described in this section when a claim is denied as being not necessary and appropriate. If so, these rights are in addition to the other rights to appeal that you have as described in other parts of this Dental Blue Freedom Benefit Description. The following provisions apply only to:

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

Blue Cross and Blue Shield decides which covered dental services are necessary and appropriate for your dental condition based on a review of your dental records and generally accepted dental practice. Some of the covered dental services described in this Dental Blue Freedom Benefit Description may not be necessary and appropriate for you. If Blue Cross and Blue Shield has determined that services are not necessary and appropriate for you, you have the right to the following appeals process:

Reconsideration
Reconsideration is the first step in this appeals process. If you receive a letter denying payment for your dental services, you may request that Blue Cross and Blue Shield reconsider its decision by writing to: Member Grievance Program, Blue Cross and Blue Shield of Massachusetts, Inc., One Enterprise Drive, Quincy, MA 02171-2126. You must submit your reconsideration request within 180 days of the adverse decision. Along with your letter, you should include any information that supports your request. Blue Cross and Blue Shield will review your request and let you know the outcome of our reconsideration request within 15 calendar days after receipt of all necessary information.

Appeal An appeal is the second step in this process. If Blue Cross and Blue Shield continues to deny benefits for all or part of the original service, you may request an appeal within 60 days of receiving the reconsideration denial letter. 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 include the name of a dentist who may review your file on your behalf. Your dentist 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 dentist in the same specialty as your attending dentist. Blue Cross and Blue Shield will notify you of the outcome of your appeal within 15 calendar days of receiving all necessary information.

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 you be responsible for half of the cost of the appeal. Your group will be responsible 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 and Blue Shield of Massachusetts, Inc., 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 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 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 requires emergency dental treatment to relieve acute pain or to control a dental condition that requires immediate care to prevent permanent harm to the member. You may request an expedited reconsideration or appeal by contacting Blue Cross and Blue Shield at the telephone number shown in your letter. Blue Cross and Blue Shield will notify you of the result of your expedited appeal within 72 hours of its receipt. 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 and Blue Shield of Massachusetts, Inc., 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 dentist 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 72 hours 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.