Please follow the instructions in this document if you disagree with our decision
regarding services that require prior approval or pre-service, as described in
the Blue Cross and Blue Shield Service Benefit Plan brochure, or a contractual
benefit determination made on a post-service claim for a service, supply,
or treatment you already received.
These steps may also be found in Sections 3, 7, and 8 of the Blue Cross and
Blue Shield Service Benefit Plan brochure. You may designate an authorized
representative of your choice, including an attorney, to act on your behalf to
appeal claims decisions to us.
For urgent care claims, a healthcare professional with knowledge of your
medical condition will be permitted to act as your authorized representative
without your express consent. For all other cases, parties acting as your
representative, such as medical providers or family members, must include a
copy of your specific written consent with the review request. You may use the
authorization form.
To prevent any delay in the review process, please ensure the form is filled out
completely, signed and dated, and included with the dispute request. For the
purposes of this section, we are also referring to your authorized representative
when we refer to you.
HOW TO FILE INTERNAL
AND EXTERNAL APPEALS
Non Urgent Pre-service
and Post-service Claims
1. Ask us in writing to reconsider our initial decision.
You must :
a. Write to us within six months from the date of
our decision; and
b. Send your request to us at the address shown on
your explanation of benefits (EOB) form for the local
Plan that processed the claim (or, for prescription
drug benefits, our Retail Pharmacy Program, Mail
Service Pharmacy Program, or the Specialty Drug
Pharmacy Program); and
c. Include a statement about why you believe our
initial decision was wrong, based on specific benefit
provisions in the brochure; and
d. Include copies of documents that support your claim,
such as physicians’ letters, operative reports, bills,
medical records, and EOB forms.
We will provide you, free of charge and in a timely
manner, with any new or additional evidence considered,
relied upon, or generated by us or at our direction in
connection with your claim and any new rationale for our
claim decision. We will provide you with this information
sufficiently in advance of the date that we are required to
provide you with our reconsideration decision to allow you
a reasonable opportunity to respond to us before that date.
However, our failure to provide you with new evidence
or rationale in sufficient time to allow you to respond
timely shall not invalidate our decision on reconsideration.
You may respond to that new evidence or rationale at the
Office of Personnel Management (OPM) review stage.
2. In the case of a pre-service claim and subject to a
request for additional information, we have 30 days
from the date we receive your written request for
reconsideration to:
a. Precertify your hospital stay or, if applicable, approve
your request for prior approval for the service, drug or
supply; or
b. Write to you and maintain our denial; or
c. Ask you or your provider for more information.
3. In the case of a post-service claim, we have 30 days
from the date we receive your request to:
a. Pay the claim; or
b. Write to you and maintain our denial; or
c. Ask you or your provider for more information.
For both non-urgent pre-service and post-service claims,
you or your provider must send the information so that we
receive it within 60 days of our request. We will then make
our decision with the new information or, if the information
was not received, with the information we already have
within 30 more calendar days. We will write to you with
our decision.
Urgent Care Claims
If you have an urgent care claim (i.e., when waiting for
your medical care or treatment could seriously jeopardize
your life, health, or ability to regain maximum function,
or in the opinion of a physician with knowledge of your
medical condition, would subject you to severe pain that
cannot be adequately managed without the requested
care or treatment), we will expedite our review of the
claim and notify you of our decision within 72 hours after
you have followed step one noted above. To request an
expedited handling of your reconsideration dispute when
this definition is met, you can call the health plan customer
service number on the back of your ID card.
We will expedite the review process, which allows
oral or written requests for appeals and the exchange
of information by telephone, electronic mail, facsimile,
or other expeditious methods.
If you fail to provide sufficient information for us to make
a decision on your expedited request, we will contact
you within 24 hours after we receive your reconsideration
request. We will allow you up to 48 hours from the receipt
of the request to provide the necessary information.
If your case warrants expedited handling, we will make
our decision on the claim within 48 hours of (1) the time
we received the additional information or (2) the end of
the 72-hour time frame, whichever is earlier.
INTERNAL APPEALS
If you do not agree with our decision, you may ask
OPM to review it. You must write to OPM within:
• 90 days after the date of our letter upholding our
initial decision; or
• 120 days after you first wrote to us – if we did not
answer that request in some way within 30 days; or
• 120 days after we asked for additional information—
if we did not send you a decision within 30 days after
we received the additional information.
Immediate Appeals
Our claims and appeals process, described in the
Blue Cross and Blue Shield Service Benefit Plan brochure,
is required to comply with the rules set forth under the
Patient Protection and Affordable Care Act. If you believe
that we have violated our claims or appeals procedures,
or that our procedures are deficient, you may immediately
appeal to OPM. However, if OPM finds that we are in
“substantial compliance” with these rules, OPM may
reject your immediate appeal. We will be in “substantial
compliance” if our failure or violation is 1) minor;
2) non-prejudicial; 3) attributable to good cause or
matters beyond our control; 4) in the context of an
ongoing good faith exchange of information; and
5) not part of a pattern or practice of non-compliance.
You may send an appeal to OPM at:
United States Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Health Insurance 1
1900 E Street, N.W.
Washington, DC 20415-3610
Note: If you want OPM to review more than one
claim, you must clearly identify which documents apply
to which claim.
Note: You are the only person who has the right to
file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include
a copy of your specific written consent with the review
request. However, for urgent care claims, a healthcare
professional with knowledge of your medical condition
may act as your authorized representative without your
express consent.
Full and Fair Review
You or your authorized representative have the right to
ask us to reconsider our claim decisions as described in
Section 8 of the Blue Cross and Blue Shield Service Benefit
Plan brochure. To help you prepare your reconsideration
request, you may arrange with us to provide a copy, free of
charge, of all relevant materials, and Plan documents under
our control relating to your claim, including those that
involve any expert review(s) of your claim. To make your
request, please contact the telephone number on the back
of your member identification card, or write to the address
on the EOB you received.
We are required to provide you, free of charge and in
a timely manner, with any new or additional evidence
considered, relied upon, or generated by us or at our
direction in connection with your claim. We will also
provide you, free of charge and in a timely manner, with
any new rationale for our claim decision. We will provide
this information sufficiently in advance of the date by which
we are required to provide you with our reconsideration
decision to allow you reasonable opportunity to respond
prior to that date. We will identify for you the medical or
vocational experts whose advice we obtained in
connection with the initial decision.
Our reconsideration will take into account all comments,
documents, records, and other information submitted by
you relating to the claim, without regard to whether such
information was submitted or considered in the initial
benefit determination.
When our initial decision is based (in whole or in part)
on a medical judgment (i.e., medical necessity,
experimental/investigational), we will consult with
a healthcare professional who has appropriate training
and experience in the field of medicine involved in the
medical judgment and who was not involved in making
the initial decision.
If we do not substantially comply with these requirements,
you may immediately appeal to OPM as explained above.
EXTERNAL APPEALS
Avoiding Conflicts of Interest
Our reconsideration decision will not afford deference
to the initial decision and will be conducted by a Plan
representative who is neither the individual who made
the initial decision that is the subject of the reconsideration,
nor a subordinate of that individual.
We will not make our decisions regarding hiring,
compensation, termination, promotion, or other similar
matters with respect to any individual (such as a claims
adjudicator or medical expert) based upon the likelihood
that the individual will support the denial of benefits.
If we do not substantially comply with these requirements,
you may immediately appeal to OPM as explained above.
Notice Requirements
We must make notices available to you in any language
where ten percent or more of the population of your
county is literate only in the same non-English language
as determined by the Secretary of Health and Human
Services. We will include on the English version of all
notices, a statement in any applicable non-English
language clearly indicating how to access language
services, including how to request a copy of the notice
in any applicable non-English language. We must also
provide oral language services (such as a telephone
customer assistance hotline) that include answering
questions in any applicable non-English language and
providing assistance with filing claims and appeals
(including external review) in any applicable non-English
language. For assistance please contact the customer
service number on the back of your identification card.
Any notice of an adverse benefit determination or
reconsideration confirmation that we send must
include sufficient information to identify the claim
involved, including the date of service, the healthcare
provider, the claim amount (if applicable), and a statement
describing the availability, upon request, of the diagnosis
code and its corresponding meaning, and the treatment
code and its corresponding meaning.
