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Important Legal Information and Disclaimers

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

Policies and Procedures

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Grievance and Appeal procedures for Prescription Drugs
Grievances

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

Example of a grievance:
If you are dissatisfied that we have removed a drug from our formulary, but you are not asking the Plan to approve coverage of the drug for you, then your complaint will be handled as 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 by phone, mail, fax, or in-person.

By phone:
Blue Medicare HMO members should call 1-888-310-4110, for the hearing and speech impaired call 1-888-451-9957 (TTY/TDD)
Blue Medicare PPO members should call 1-877-494-7647, for the hearing and speech impaired call 1-888-451-9957 (TTY/TDD)
Blue Medicare Rx (PDP) members should call 1-888-247-4142, for the hearing and speech impaired call 1-888-247-4145 (TTY/TDD)
Seven days a week
8 a.m. to 8 p.m.

By mail:
Blue Cross Blue Shield of North Carolina
Attn: Medicare Part D Grievance
P.O. Box 17509
Winston-Salem, NC 27116-7509

By fax:
(336) 794-8836
1-888-375-8836

In person:
Blue Cross Blue Shield of North Carolina
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

Please see your Evidence of Coverage for a detailed explanation of the grievance procedures and timeframes for a response. Refer to the Evidence of Coverage for your plan.

Appeals

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 non-formulary 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 or your prescriber may file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice and must be in writing, unless you are filing an expedited or fast appeal. You may file your appeal by:

Mail:
Blue Cross Blue Shield of North Carolina
Attn: Medicare Part D Appeal
P.O. Box 17509
Winston-Salem, NC 27116-7509

Fax:
(336) 794-8836
(888) 375-8836

In-person:
Blue Cross Blue Shield of North Carolina
5660 University Parkway
Winston-Salem, NC 27105
Mon. - Fri., 8 a.m. - 5 p.m.

Email:
A Part D appeal by email must include the member's:

  • Full name
  • Member ID number (see your member ID card)
  • Date of birth
  • Phone number
AND
  • The name of the drug for which the appeal is being requested
  • The name and telephone number of the person who prescribed the drug
  • The reason you think the drug should be covered
Send Part D appeal emails to: PartDAppeals@bcbsnc.com

A specific form is not required for you to file an appeal; however, a form is available for your use by clicking on the link below. Completion of this form may help you with your review request and assist us in the review process.

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 seven (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 timeframes 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.

Appointing a representative

A Medicare beneficiary may appoint an individual to act as his/her representative in filing an 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

Please see your Evidence of Coverage for a detailed explanation of the appeals procedures and timeframes for a response. Refer to the Evidence of Coverage for your plan.



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Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2013.

Y0079_6246 CMS Approved 10212013