Skip Navigation

Important Legal Information and Disclaimers

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

Policies and Procedures

  • Text Size
  • Decrease Text Size
  • Increase Text Size
Blue Medicare HMO and Blue Medicare PPO Medical Appeals and Grievances

Grievances

A grievance is a type of complaint that you may file if you are dissatisfied with Blue Medicare HMO or Blue Medicare PPO or with a contracted provider. This type of complaint does not involve coverage or payment disputes. Grievances can include complaints regarding the timeliness, appropriateness, access to, or the quality of your care.

Example of a grievance:
If you are dissatisfied that you had difficulty getting through to us via the phone lines, 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.

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.

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)
Seven days a week
8 a.m. to 8 p.m.

By mail:
Blue Cross Blue Shield of North Carolina
Attn: Medicare Appeal and Grievance Department
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.

Appointment of Representative form

If you are dissatisfied with the quality of care you have received, you may also file your grievance with the Quality Improvement Organization (QIO). The Quality Improvement Organization for North Carolina is KEPRO.

You may contact KEPRO:

By phone:
1-844-455-8708 or for the hearing and speech impaired call 1-855-843-4776 (TTY/TDD)

By mail:
5201 W. Kennedy Blvd.
Suite 900
Tampa, FL 33609

By website:
www.keproqio.com

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.

If we have denied your request for an expedited coverage decision or an expedited appeal or if we have taken a 14 calendar day extension on the time frame for a coverage decision or appeal, and you disagree with those actions, you may file an expedited or fast grievance. Our response will be provided within 24 hours.

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

How do I file an appeal?

Standard Appeals

You can appeal a denied Notice of Denial of Medical Coverage decision, Notice of Denial of Payment decision, or if you are disputing a Copayment or Coinsurance amount you are being billed for, by sending a written, signed request detailing why you think the denial should be overturned. If you cannot file an appeal, you may designate someone, in writing, to 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.

Appointment of Representative form

An appeal must be filed within 60 calendar days of the denial notice that we sent to you.

You may file your appeal by:

Mail: Blue Cross Blue Shield of North Carolina
Attn: Medicare Appeals and Grievances Department
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.

We will investigate your concern(s) and respond to you in writing. Our response to a standard appeal of a Notice of Denial of Medical Coverage will be sent within 30 calendar days of the Plan's receipt of the appeal, or within 44 calendar days if an extension was taken. Our response to an appeal of a Notice of Denial of Payment will be sent within 60 calendar days of the Plan's receipt of the appeal.

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. Note: An appeal request for a Notice of Denial of Payment or Copayment or Coinsurance dispute cannot be expedited.

To file an Expedited or Fast appeal:

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)
Seven days a week
8 a.m. to 8 p.m.

By mail:
Blue Cross Blue Shield of North Carolina
Attn: Medicare Appeal and Grievance Department
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.

If calling after business hours, just follow the prompts to file an expedited or fast appeal.

When will I receive a decision on my 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.

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.

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.



Get Acrobat   To view PDF documents you need Adobe Acrobat Reader.

Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2015.

Y0079_7169 CMS Approved 11102015