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Grievance procedures for prescription drugs

A grievance is a complaint that you may file if you are dissatisfied with Blue Medicare HMO or Blue Medicare PPO, or with a contracted provider for reasons other than a decision on a coverage determination. Grievances also include complaints regarding the timeliness, appropriateness, access to, or setting of a covered prescription drug.

Example of a grievance:
If you have a complaint that a particular drug is not on your Medicare prescription drug package's formulary and wish to express your dissatisfaction with this, but you are not asking the Plan to approve coverage of the drug, then you may file a grievance.

How do I file a grievance?

The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You or your appointed representative may file a grievance via:

Case management programs

In certain health situations, members are eligible to work one-on-one with a case manager. You may be eligible for a case manager if you:

• Have a qualifying complex, chronic disease
• Are at risk for developing a complex and serious medical condition (This may be determined by your answers to the Health Risk survey that you completed during enrollment.)
• Have been involved in an accident or other catastrophic health event
• Need assistance managing your health care needs

Case managers are available at no additional cost, but copayment and coinsurance for covered services may apply. Case managers can help you:

• Navigate the health care system
• Identify, implement and monitor your health care needs
• Learn how to prevent falls
• Eliminate barriers to receiving care
• Learn more about your disease, benefits and medications
• Find resources in your community
• Coordinate services such as home health, skilled nursing facilities, inpatient rehabilitation, hospice, durable medical equipment, transplants and more.

To request services from a Blue Medicare HMO or Blue Medicare PPO case manager, please contact Customer Service 7 days a week, 8am to 8pm:

Blue Medicare HMO

1-888-310-4110

Blue Medicare PPO

1-877-494-7647

For the hearing and speech impaired

1-888-451-9957 (TTY/TDD)

Seven days a week
8 a.m. - 8 p.m.

Mail:
Blue Medicare HMO or Blue Medicare PPO
Attn: Appeals and Grievance Unit
P.O. Box 17509
Winston-Salem, NC 27116-7509

Fax:
(336) 794-8836

In-person:
Blue Medicare HMO, Blue Medicare PPO
5660 University Parkway
Winston-Salem, NC 27105
Mon. - Fri., 8 a.m. - 5 p.m.

When will I receive a decision on my grievance?

The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after our receipt of the grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after receipt of the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.

You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after our receipt of the grievance.

Appointing a representative

A Medicare beneficiary may appoint an individual to act as his/her representative in filing a grievance. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a grievance. A grievance by a representative is not valid until the Appointment of Representative form below is completed and submitted, or other equivalent form, legal papers or authority are submitted.

Appointment of Representative form

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Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.

The information on this page is current as of 11/4/08.