If you are dissatisfied with something related to your Blue Medicare HMO or Blue Medicare PPO coverage, please let us know by calling Customer Services 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. We will try to resolve your concern at the time of the call or within 30 days of your call. If you cannot file a grievance, someone you designate in writing as your appointed representative can file a grievance for you. An Appointment of Representative form should be completed and accompany the oral or written grievance.
If we do not resolve your concern informally over the phone or if you wish to file a written, formal grievance, you should send us a written signed letter that explains in detail the reason for your dissatisfaction. Mail your grievance to:
You will receive a written reply to you Grievance within 30 calendar days after we receive your letter.
If we have denied your request for an expedited coverage decision or appeal or if we have taken a 14 calendar day extension on the time frame for a coverage decision or appeal, and your are dissatisfied with those actions, you may file an expedited or fast grievance. Our response will be provided within 24 hours.
You can appeal a denied Notice of Denial of Medical Coverage decision or a Notice of Denial of Payment decision by sending a written, signed letter detailing why you think the denial should be overturned. If you cannot file an appeal, someone you designate in writing as your appointed representative can file an appeal for you. An Appointment of Representative form should be completed and accompany your written appeal. Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.
An appeal must be filed within 60 calendar days of the denial notice that we sent to you.
Expedited or Fast Appeals
If you or your doctor believes that waiting on a standard appeal decision on a Notice of Denial of Medical Coverage could seriously harm your health or your ability to function, you, your authorized representative or your doctor can ask for an expedited or fast appeal.
To file a fast appeal call Customer Service:
Seven days a week
8 a.m. - 8 p.m.
If calling after business hours, just follow the prompts to file an expedited or fast appeal.
We will respond by phone and in writing to an expedited appeal within 72 hours of our receipt of the expedited or fast appeal request. If someone other than you or your physician decides to file an expedited or fast appeal for you, an Appointment of Representative form must be received before the appeal review can begin.
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. Refer to the Evidence of Coverage for your plan.
To obtain an aggregate number of Medicare Advantage Plan appeals and quality of care grievances, 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.
Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.
Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.
Limitations, copayments, and restrictions 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 you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.
The information on this page is current as of 10/01/2012.
Y0079_5875 CMS Approved 10012012