Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members

Policies and Procedures

Coverage determinations, appeals and grievances

Review a description of our procedures for obtaining a coverage determination, or for appealing a coverage determination decision or for filing a grievance if you are dissatisfied for any reason.

To obtain an aggregate number of Blue Medicare Rx Plans grievances and exceptions, you may call Customer Service at 1-888-247-4142 (toll-free).


Overview of Blue Medicare Rx Plan coverage determinations, appeals and grievances top

Blue Cross and Blue Shield of North Carolina offers you all the rights afforded under Federal law and Centers for Medicare and Medicaid (CMS) regulations and guidelines for your Blue Medicare Rx Plan.

It is our goal to respond to all requests for a coverage determination, an appeal or a grievance from you or your appointed representative in a timely manner as required by CMS, and as described in more detail in your Evidence of Coverage.

What is a coverage determination? top

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. (Also see the description of the exceptions process.) You must contact us if you would like to request a coverage determination, including an exception. You cannot request an appeal if we have not issued a coverage determination.

The following are examples of when you may ask us for a coverage determination:

  • If you are not getting a prescription drug that you believe may be covered by us
  • If you have received a Part D prescription drug that you believe may be covered by us while you were a member, but we have refused to pay for the drug
  • If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped and that you believe you have extenuating circumstances that should exclude you from the reduction/non-coverage
  • If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation
  • If you bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense

How do I make a request for a coverage determination?

To ask for a standard decision, you or your appointed representative may call our Customer Service Department at the numbers listed on the back cover. You can also deliver a written request to BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8:00 a.m. - 5:00 p.m. You may fax your request to 1-888-446-8440.

To ask for a fast decision, you, your physician, or your appointed representative may call us at the Customer Service Department at the numbers listed on the back cover. You can also deliver a written request to BCBSNC, 5640 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8:00 a.m. - 5:00 p.m. You may fax your request to 1-888-446-8440. After regular business hours, you should consult with a contract pharmacy regarding your need for an emergency or temporary supply of medication until you can contact the Plan the next business day. Be sure to ask for a "fast," "expedited," or "24-hour" review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased.

When will I hear back with a decision?

Generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), we must make our decision no later than 72 hours after we have received your doctor's "supporting statement," which explains why the drug you are asking for I medically necessary. If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible. We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the timeframe explained above. If we do not approve your request, we must explain why and tell you of your right to appeal our decision.

If you get a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review-sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor's "supporting statement."

What is an exception request?

Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that:

  • Is not on the formulary (list of drugs the plan covers)
  • Requires prior authorization
  • Has quantity limitations

Example of an exception request:

If the Plan's formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.

How do I make an exception request?

You or your prescribing physician may request an exception to the coverage rules for your Blue Medicare Rx.

Phone:
1-888-247-4142 TTY/TDD 1-888-247-4145
7 days a week, 8:00 a.m. - 8:00 p.m.
Physicians should call:
1-888-298-7552 or Fax to: 888-446-8440

Mail:
BCBSNC
Attn: Coverage Determination
P.O. Box 17168
Winston-Salem, NC 27716-7168

A specific form is not required for you to make an exception request. The request must include your prescribing physician's statement that he/she has determined that the preferred drug either would not be as effective for you and/or would have adverse effects for you.

When will I receive a decision on my exception request?

We will review the exception request and notify both you and your prescribing physician of our decision as soon as your health requires, but no later than 72 hours from the date and time we receive your physician's supporting statement. Faster exception decisions are available if this 72-hour time frame could seriously harm your health or ability to function. If the decision is not in your favor, the notice will be given by phone, followed by a written notice (within three days). The notice will tell you how to pursue your appeal rights if you are dissatisfied with our decision.

What is an appeal? top

An appeal is your opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests.

Example of an appeal:

If we deny your request for an exception to cover a nonformulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan.

How do I file an appeal?

If you receive a coverage determination denial, you or your appointed representative may file an appeal. A specific form is not required for you to file an appeal. An appeal must be filed within 60 calendar days of the date of a denial notice and must be in writing, unless you are filing an expedited or fast appeal. You must submit it via:

Mail:
BCBSNC
Attn: Appeals and Grievance Unit
P.O. Box 17168
Winston-Salem, NC 27116-7168

Fax:
336-794-8836 or
1-888-375-8836

In person:
BCBSNC
5660 University Pkwy.
Winston-Salem, NC 27105

When will I receive a decision on my appeal?

We will perform a standard review of your appeal as soon as your health requires but no later than 7 calendar days after we receive your appeal. We will review requests for an expedited or fast appeal as soon as possible, but no later than 72 hours following our receipt of the request. An individual who was not involved with your original coverage determination will make a decision on your appeal. You will receive a written response to your appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If our decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. If we miss our time frames for claims adjudication or review of the appeal, we will automatically forward the appeal to the IRE for a decision. There may be additional levels of appeal available to you. We will inform you of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details.

What is a grievance? top

A grievance is a complaint that you may file if you are dissatisfied with the Plan or 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 the Plan's formulary and wish to express your dissatisfaction with this, but you are not asking the Plan to approve coverage of the drug, then this would be 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: the phone, by mail, fax, or in-person.

Phone:
1-888-247-4142
7 days a week, 8:00 a.m. - 8:00 p.m.

Mail:
BCBSNC
Attn: Appeals and Grievance Unit
P.O. Box 17168
Winston-Salem, NC 27116-7168

Fax:
336-794-8836 or
1-888-375-8836

In person:
BCBSNC
5660 University Pkwy.
Winston-Salem, NC 27105

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 time frame 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 to 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.

What if I have a concern about the quality of services I received?

If you have a concern relating to the quality of services that you received under the Medicare Part D plan, then in addition to our review, you can also request review by the following organizations:

The Carolinas Center for Medical Excellence (CCME)

The CCME, formerly known as Medical Review of North Carolina Inc., is a nonprofit, health care quality improvement organization. CCME has been designated by the Centers for Medicare & Medicaid Services as the Quality Improvement Organization (QIO) for North Carolina. The QIO reviews complaints about quality of care and provides immediate review of non-coverage determinations when Medicare patients think that coverage of the following services is ending too soon: inpatient hospital stay, skilled nursing facility stay, home health care, or comprehensive outpatient rehabilitation facility stay. Assistance is available, Monday - Friday, 8:00 a.m. - 5:00 p.m. by calling:

For QIO appeals: 1-800-682-2650
For hotline complaints: 1-800-722-0468
For TTY/TDD calls: dial 711 (This is North Carolina's text telephone line that connects standard phone users and those people who use a text phone.)
For Web inquiries: www.mrnc.org

Seniors' Health Insurance Information Program (SHIIP)

SHIIP is a state consumer division of the North Carolina Department of Insurance. SHIIP assists senior citizens with Medicare, Medicare Part D, Medicare supplements, Medicare Advantage, Medicare fraud and abuse, and long-term care insurance questions. Assistance is available by calling 1-800-443-9354 (for the hearing impaired: TTY/TDD 1-800-735-2962), Monday - Friday, 8 a.m. - 5 p.m. You may also send an e-mail to ncshiip@ncdoi.net or visit SHIIP's Web site at www.ncshiip.com.

Appointing a representative top

Medicare beneficiaries may appoint an individual to act as their representative in filing a grievance or appeal. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file an appeal. An appeal 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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The information on this page is current as of 10/01/2009.