Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx Members
Policies and Procedures
Blue Medicare HMO and Blue Medicare PPO Appeals and grievances
If you are dissatisfied with something related to your Blue Medicare HMO or Blue Medicare PPO coverage, please let us know. We will try to resolve any complaint that you might have over the phone. If we cannot resolve your complaint over the phone, we will give you details on filing a formal grievance. Your complaint will be reviewed through the Grievance Procedure.
To obtain an aggregate number of Medicare Advantage Plan grievances and exceptions, you may call Customer Service at 1-888-310-4110 (toll-free) for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, 1-888-451-9957 (TDD/TTY), 7 days a week, 8am to 8pm.
Standard appeals
You can also appeal a coverage decision. To file a standard appeal, you or your authorized representative should send a written request to:
Blue Medicare HMO or Blue Medicare PPO
Appeals and Grievances Department
P.O. Box 17509
Winston-Salem, NC 27116-7509
Fast appeals
If you or your doctor believe that waiting on a standard decision could seriously harm your health or your ability to function, you, your authorized representative or your doctor can ask for a fast appeal.
To file a fast appeal call Customer Service:
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.
If calling after business hours, just follow the prompts to file a fast appeal.
Appealing a Notice of Medicare Non-Coverage
If you receive an advance Notice of Medicare Non-Coverage for skilled nursing, home health or comprehensive outpatient rehabilitation services from the provider of the service, you are entitled to file an appeal with the Quality Improvement Organization (QIO), rather than Blue Medicare HMO or Blue Medicare PPO, regarding the upcoming termination of services. Please follow the instructions contained in the Notice for the steps to follow to file an appeal with the QIO.
Please see your Evidence of Coverage for a detailed explanation of the appeals and grievance procedures and timeframes for a response.
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 10/01/2009.