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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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Blue Medicare HMO Medical Appeals and Grievances

Grievances

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 (toll free) for Blue Medicare HMO at 1-888-310-4110, for Blue Medicare PPO at 1-877-494-7647, or 1-888-451-9957 (TDD/TTY), 7 days a week, 8 a.m. to 8 p.m. 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.

Appointment of Representative form

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:

    Medicare Appeal and Grievance Department
    P.O. Box 17509
    Winston-Salem, NC 27116-7509

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.

Standard Appeals

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.

Appointment of Representative form

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

  • You should mail your written, appeal to:
    Medicare Appeals and Grievances Department
    P.O. Box 17509
    Winston-Salem, NC 27116-7509
  • 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 Planís receipt of the appeal. Our response to an appeal of a Notice of Denial of Payment will be sent within 60 calendar days of the Planís 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.

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 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.



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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