Complaints and Appeals - Medicare
Blue Advantage - Complaints & Appeals
Blue Advantage Complaints & Appeals
- What is a grievance?
- What is an Organization Determination?
- What is an appeal?
- What is a coverage determination?
- What if I need my request expedited?
- How to submit a grievance?
- How to submit a Medical appeal?
- How to submit an Organization Determination?
- How to appoint a representative?
- How to find additional information about grievances, coverage determinations, and appeals?
- How do I obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Advantage?
- What is Best Available Evidence (BAE)?
A grievance is a type of complaint you make about Blue Advantage or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Your grievance must be made within 60 days after you had the problem you want to make a complaint about. We will respond to your complaint within 30 days after receiving your request, but may take up to 44 days.
An organization determination is a decision we make about your benefit and coverage or the amount we will pay for your medical services.
There are two kinds of organization determinations:
- Standard organization determinations. For standard medical care requests, we must respond to your request within 14 days after we receive your request.
- Fast organization determinations. If your health requires it, you can ask for a "fast coverage determination". We will answer fast coverage determinations within 72 hours if you meet the two requirements. You can get a fast decision for only medical care not received or using the standard deadlines could cause serious harm to your health or hurt your ability to function. However, it may take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for review. If we decide to take extra days, we will tell you in writing.
An appeal is something you do if you disagree with a decision to deny a request for healthcare services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Blue Advantage doesn't pay for a drug, item or service you think you should be able to receive.
There are two kinds of Part D appeals:
- Standard appeal. For coverage or payment appeals, we must respond to your request within 7 calendar days after we receive your appeal.
- Expedited appeal. If your health requires a quick response, you can ask for an expedited appeal. We must respond to your request within 72 hours after we have received your appeal.
You must make your medical appeal request within 60 calendar days from the date on the written notice we sent to tell you your Blue Advantage's answer to your request for a coverage decision. Medical appeals are reviewed and determinations returned within 60 calendar days upon receiving all necessary information.
A decision about whether a drug prescribed for you is covered by Blue Advantage and the amount, if any, you are required to pay for the service or prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under Blue Advantage, that isn't a coverage determination. To ask for a formal decision about the coverage if you disagree, print and complete the appropriate form below and fax it to 1-800-693-6703 or mail to Prime Therapeutics LLC, Attention: Part D Appeals Department, 1305 Corporate Center Dr. Building EC, Eagan, MN 55121:
- Request for Coverage Determination
- Request for Redetermination or Physician Drug Authorization Request Form - Plan Version
If you or your health care provider believe that waiting for a decision under the standard time frame may place your life, health, or ability to regain maximum function in serious jeopardy, an expedited medical appeal may be requested. Once all necessary information is received, your request will be reviewed and a determination sent to you and all necessary parties within 24 hours.
You may file a grievance with our Plan either by phone or in writing. To contact us by phone, please call Blue Advantage Member Services at 1-888-234-8266 8 a.m.. to 8 p.m., seven (7) days a week. From April 1 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. TTY users should call 711. To contact us in writing, please submit your signed grievance to:
Blue Cross and Blue Shield of Alabama
P.O. Box 995
Birmingham, AL 35298
You may also submit feedback about your Medicare health plan or prescription drug plan directly by visiting https://www.medicare.gov/MedicareComplaintForm/home.aspx, in lieu of calling 1-800-Medicare.
For medical appeals, send requests to:
Attention: CSD Appeals
P.O. Box 725
Birmingham, AL 35201-0725
You, your doctor or representative may submit an organization determination with our Plan by phone, fax or in writing. To contact us by phone please call Blue Advantage Member Services at 1-888-234-8266 8:00 A.M. to 8:00 P.M., seven (7) days a week. From April 1 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. TTY users should call 711. Faxed requests should be sent to 205-220-9560. To contact us in writing, please submit your signed request to :
Blue Cross and Blue Shield of Alabama
Attention: Blue Advantage Medical Review
P.O. Box 362025
Birmingham, AL 35236
An enrollee may appoint any individual (such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payor) to act as his or her representative. A representative who is appointed by the court or who is acting in accordance with State law may also file a request for a coverage determination or appeal on behalf of an enrollee. The enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an Appointment of Representative form (CMS-1696 Form).
You can find additional information about our grievance, coverage determination (including exceptions), and appeals process by reviewing the Evidence of Coverage, Chapter 9, for your plan.
How do I obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Advantage?
To obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Advantage contact Member Services at 1-888-234-8266 or TTY 711 8 a.m. to 8 p.m., seven (7) days a week. From April 1 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day.