Medical Care Appeals and Grievances | Blue Cross and Blue Shield of Texas

Medical Care Appeals and Grievances

Asking for a Coverage Decision for Medical Care

You have a right to ask us to provide or pay for items or services you think should be covered, provided or continued. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. When a coverage decision involves your medical care, it is called an "organization determination."

Asking for a Coverage Decision

If you want to know if we will cover a medical service before you get it, you can ask us to make a coverage decision for you. A coverage decision is made about your benefits and coverage or about the amount we will pay for your medical services or drugs. You or your doctor can ask for a coverage decision if you aren’t sure if your plan covers a medical service or if care is refused for a medical service you think that you need. If you disagree with this coverage decision, you can make an appeal (see below contact information ‘Filling a Medical Appeal’).

Your physician or an office staff member may request a medical prior authorization by calling customer service toll-free at:

Blue Cross Medicare Advantage Dual Care Plans: 1-877-895-6437 TTY/TDD 711

You can also fax the request to: 1-855-874-4711

Or mail the request to:
Blue Cross Medicare Advantage
c/o UM Intake
P.O. Box 4288
Scranton, PA 18505

Asking to Authorize or Provide Medical Care Coverage

Call, mail or fax your request to the plan to authorize or provide coverage for the medical care you want. You, your doctor, or your appointed representative can do this. See below for contact information.

Phone:
1-877-895-6437 TTY/TDD 711

Fax Number:
1-855-674-9185

Mailing Address:
Blue Cross Medicare Advantage Dual Care
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505

Filing a Medical Grievance

Appeals: You can ask for an appeal: If coverage or payment for an item or medical service is denied that you think should be covered.

Expedited Appeals: You can ask for an expedited (fast) appeal if:

  • Coverage was denied and your health requires a quick response, or
  • You think that your covered services in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility is ending too soon

Grievances: You can file a grievance if you have a complaint about the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above. If you have coverage issues related to medical or pharmacy services, or if you or your appointed representative wishes to file a grievance, please contact customer service.

You may also contact Blue Cross Medicare Advantage Dual Care if you want information about the number of appeals, grievances, or exceptions filed with the plan.

Types of Problems Might Lead to You Filing a Grievance

These issues may be reasons to file a grievance.

  • You feel that you're being encouraged to leave (disenroll from) our plan.
  • Problems with the customer service you get.
  • Problems with how long you wait on the phone or in the pharmacy or medical office.
  • Disrespectful or rude behavior by pharmacists or other medical staff.
  • Cleanliness or condition of pharmacy or medical office.
  • You disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
  • You believe our notices and other written materials are hard to understand.
  • Failure to give you a decision within the required timeframe.
  • Failure to forward your case for an independent review if we don't give you a decision within the required timeframe.
  • Failure by the plan sponsor to provide required notices.
  • Failure to provide required notices that comply with CMS standards.

If you have a grievance, we ask you to first call Customer Service at 1-877-895-6437 TTY/TDD 711.

You can also send us your grievance in writing to:
Fax Number:
1-855-674-9185

Mailing Address: Blue Cross Medicare Advantage Dual Care
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505

Resolving Your Concerns

You must file a grievance with us no later than 60 days after the event or incident in question.

By Telephone:

We try to resolve any complaint you have over the phone. If Customer Service cannot resolve your concern over the phone, we have a formal process to review your complaints. We have made this process easy to follow so you will get a timely response. If your concern is not resolved at the time of your first phone call, it will be sent on to a grievance coordinator to be resolved. Generally, you will be sent a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after we get it.

If your grievance involves the quality of the care you received, you will get a written response. We may add to the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for more information and the delay is in your best interest. When we add to the deadline, we will immediately let you know the reason(s) for the delay in writing.

If you or your appointed representative wants to file a grievance, please contact customer service at 1-877-895-6437 TTY/TDD 711.

By Mail:

You may file a grievance in writing by sending a letter telling us about your grievance:

Blue Cross Medicare Advantage Dual Care
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505

Fax Number: 1-855-674-9189

You will get a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after we get your complaint. We may add to the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for more information and the delay is in your best interest. When we add to the deadline, we will immediately let you know the reason(s) for the delay in writing.

Additional forms and information on Appeals and Grievances

Appointment of Representative

You may choose someone to act on your behalf. You may choose a relative, friend, sponsor, lawyer or a doctor. A court may also appoint someone. You and the person you choose must sign, date, and complete a representative statement.

A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement. The representative statement must include your name and Medicare claim number. You can use the CMS Appointment of Representative form - CMS-1696-U4 or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices.

Others may already be authorized under State law to be your representative.

Medicare Contact Information

You can contact Medicare for more information about benefits and services, including general information about Medicare Advantage Prescription Drug coverage.

Telephone
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week
If you are hearing or speech impaired, please call 1-877-486-2048.

Online
www.medicare.gov

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.

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