Member appeals

Appeals Department
Blue Cross and Blue Shield of North Carolina
P.O. Box 30055
Durham, North Carolina 27702-3055

First level grievance review

The first step of the formal appeal process is the first level grievance review. The review should be requested, preferably in writing, within 180 days of a denial of benefit coverage. To request a form to submit a request for a first level grievance review, you may contact BCBSNC Customer Service at the number on the back of your ID card or you may print a form from BCBSNC’s external Web site (www.bcbsnc.com).

Any request for review should include:

• Subscriber’s ID number
• Subscriber’s name
• Patient’s name
• The nature of the grievance
• Any other information that may be helpful for the review

Within three business days after receipt of a review request, BCBSNC will provide you with the name, address and phone number of the grievance coordinator. BCBSNC will also give you instructions on how to submit written materials. Although you are not allowed to attend a first level grievance review, BCBSNC asks that you send all of the written material you feel is necessary to make a decision. BCBSNC will use the material provided in the request for review, along with other available information, to reach a decision. You will be notified of the decision in clear written terms, within 30 days from the date BCBSNC receives the request for a review.

Second level grievance review

If you or your authorized representative is dissatisfied with the first level grievance review decision, you have the right to a second level grievance review. Second level grievances are not allowed for benefits or services that are clearly excluded by this benefit booklet or quality of care complaints. The request must be made in writing within 180 days of the first level grievance review decision. Within 10 business days after BCBSNC receives your request for a second level grievance review, the following information will be given to you:

• Name, address and telephone number of the grievance coordinator
• A statement of your rights, including the right to:
  • Request and receive from us all information that applies to your case
  • Attend the second–level grievance
  • Present your case to the review panel
  • Submit supporting material before and at the review meeting
  • Ask questions of any member of the review panel
  • Be assisted or represented by a person of your choosing, including a family member, employer, representative or attorney.

The second level review meeting, which will be conducted by an external review panel, will be held within 45 days after BCBSNC receives a second level grievance review request. You will receive notice of the meeting date and location at least 15 days before the meeting. You have the right to a full review of your grievance even if you do not attend the meeting. A written decision will be issued to you within five business days of the review meeting.

If you have insurance–related problems or questions, you may contact the North Carolina Department of Insurance for assistance.

Inquiries may be directed by calling 1-800-662-7777 or by writing to the:

Expedited review

You or your authorized representative have the right to request a more rapid or expedited review of a denial of coverage if a delay would reasonably appear to seriously jeopardize you or your dependent’s life or health or jeopardize you or your dependent’s ability to regain maximum function. You can request an expedited second level review even if you did not request that the initial review be expedited. An expedited review may be requested by calling BCBSNC Customer Service at the number on the back of your ID card or in your member handbook. An expedited review of a denial of benefit coverage will take place in consultation with a medical doctor. All of the same conditions for a first level or second level grievance review apply to an expedited review, except that the review meeting will take place through a conference call or through written communication. BCBSNC will communicate the decision by phone to you and your provider as soon as possible but no later than 72 hours after receiving the request for the expedited appeal. A written decision will be communicated within four days after receiving the request for the expedited appeal. Information initially given by telephone must also be given in writing. After requesting an expedited review, BCBSNC will remain responsible for covered health care services you are receiving until you have been notified of the review decision.