  Provider resources and informationGrievance proceduresA grievance is a complaint that members may file if they are dissatisfied with Blue Medicare PPO or Blue Medicare HMO, or with 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 members have a complaint that a particular drug is not on their Medicare prescription drug package's formulary and wish to express their dissatisfaction with this, but they are not asking the Plan to approve coverage of the drug, then the member may file a grievance. How do I file a grievance?The grievance must be filed within 60 days after the event or incident that caused the member to be dissatisfied. A specific form is not required for the member to file a grievance. The member or their appointed representative may file a grievance via: Phone: Mail: Fax: In-person: When will I receive a decision on my grievance?The resolution of a grievance will be made as quickly as the member's concern requires, but no more than 30 calendar days after the plan’s receipt of the grievance. The plan may extend the timeframe by up to 14 calendar days if the member requests the extension, or if the plan justifies a need for additional information and the delay is in the member's best interest. If the member requests 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. The plan's decision on a grievance is final and is not subject to an appeal. The member has the right to an expedited review of a grievance concerning the plan’s refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after the plan's receipt of the grievance. Appointing a representativeA 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
Blue Cross and Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries 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 not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. |
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