Appeals & Grievances

 

You can file a complaint if you have concerns or problems relating to your:

  • Medicare Advantage plan

  • Prescription drug coverage

  • The service you receive

You can also request to get a total number of appeals, grievances, and exceptions that members have filed against our plan in the past.

To get this information, call Member Service at 1-800-200-4255 (TTY users call: 711)

October 1 through February 14, 8:00 a.m. to 8:00 p.m. EST., 7 days a week, and February 15 through September 30, 8:00am to 8:00pm ET., Monday through Friday.

Medicare Advantage Part C Medical Care Plan Rights

Learn about your Part C medical care plan’s rights, including:

  • Grievances

  • Coverage decisions

  • Exceptions

  • Appeal processes

For more detailed information, refer to Chapter 9 of the Evidence of Coverage.

 

Your Part C Medical Care Plan Rights

You have certain rights concerning your medical care. Specifically, you have the right to:

  • Request a coverage decision

  • Make an appeal to deal with problems related to your benefits and coverage for medical services

Asking for coverage decisions

A coverage decision is a determination we make about your benefits and coverage, or about the amount we'll pay for your medical services. We make a coverage decision for you whenever you go to a doctor or other provider for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we'll cover a medical service before you receive it, you can ask us to make a coverage decision for you.

In some cases, we might decide a service or drug isn't covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Contact Information for Coverage Decisions About Your Medical Care and Services

Phone:

Call 1-800-200-4255 (TTY/TDD: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. There is no charge for calls made using these numbers.

Fax:

For emergency inpatient acute hospital admissions: 1-866-577-9678.

For all other requests:
1-800-477-2994.

There is no charge for calls made using these numbers.

Mail:

Blue Cross Blue Shield of Massachusetts
Member Service
P.O. Box 55007
Boston, MA 02205

How to make a complaint (file a grievance)

This section explains how to use the process for making complaints. The formal name for "making a complaint" is called "filing a grievance." The complaint process is only used for certain types of problems. This includes issues related to quality of care, waiting times, and the customer service you receive.

What types of items might lead to filing a grievance?

  • Unresolved issues with Member Service

  • Problems with one of our network providers

  • Disagreement with any of our policies or benefit design

  • Suspicion of fraud or abuse

  • Marketing or sales activities that you feel are inappropriate

Step 1: Contact us promptly—either by phone or in writing. (For Steps 2 and 3, see the 'Standard & Expedited Reviews' tab)

  • Usually, calling Member Service is the first step. If there is anything else you need to do, Member Service will let you know.

Phone:

You can call Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

  • If you do not wish to call (or you called and weren't satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we'll use our formal procedure for answering grievances.

How we formally respond to grievances

All written grievances must be submitted to us within 60 days of the event or incident that caused your complaint. Your written grievance must contain:

  • Your name

  • Address and Membership number

  • Your signature, or that of an authorized representative, including the date on which it is signed

  • A description of the specific event and the date on which it occurred

Write Us

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Grievance Coordinator
P.O. Box 55007
Boston, MA 02205

Fax:

1-617-246-8506

Quality of Care Complaints

When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO).

  • The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.

  • To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of your Evidence of Coverage. If you make a complaint to this organization, we'll work with them to resolve your complaint.

  • If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:

  • You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

How do I appoint a representative to help with a claim and authorize them to act on my behalf?

If you want a friend, relative, your doctor or other provider, or another person to be your representative, you must complete this Medicare Advantage Appointment of Representative Form. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

Medicare Complaint Form

You can now submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services (CMS) values your feedback, and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call.

1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

How to make an appeal

If we make a coverage decision and you're not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to see if we were being fair and following all of the rules properly. When we have completed the review, we give you our decision.

If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that isn't connected to our plan. If you're not satisfied with the decision at the Level 2 Appeal, you may be able to continue through three more levels of appeal.

Get help asking for a coverage decision or making an appeal

  • Call Member Service at the phone number listed below.

  • To get free help from an independent organization that isn't connected with our plan, contact your State Health Insurance Assistance Program (SHIP).

  • You should consider getting your doctor or other provider involved if possible, especially if you want a "fast" or "expedited" decision. In most situations involving a coverage decision or appeal, your doctor or other provider must explain the medical reasons that support your request. Your doctor can't request every appeal. He/she can request a coverage decision and a Level 1 Appeal with the plan. To request any appeal after Level 1, your doctor must be appointed as your "representative."

Assigning a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.

If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete this
Medicare Advantage Appointment of Representative Form. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

Appeal Review Time Frames

Standard Appeal
If we're using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal, if your appeal is about covered services you have not yet received. We'll give you our decision sooner if your health condition requires us to—however, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days.

Fast Appeal
When we're using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We'll give you our answer sooner if your health condition requires us to do so. However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we'll tell you in writing.

Contact Information for Coverage Decisions About Your Medical Care and Services

Phone:

Call 1-800-200-4255 (TTY/TDD: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. There is no charge for calls made using this number.

Fax:

1-617-246-8506

Online:

Requests for coverage determinations and redeterminations may be submitted through email.

Mail:

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205

Time Frames for Standard and Expedited Reviews for Coverage Decisions

Standard Deadlines

When we give you our decision, we'll use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we'll give you an answer within 14 days after we receive your request.

  • In some cases, we can take up to 14 more days if you ask for more time, or if we need more information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

Fast Decision

A fast decision means we'll answer within 72 hours.

  • In some cases, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.

  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. We will call you as soon as we make the decision.

To get a fast decision, you must meet two requirements:

  • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)

  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a "fast decision," we'll automatically agree to give you a fast decision.

  • If you ask for a fast decision on your own, without your doctor's support, our plan will decide whether your health requires that we give you a fast decision.

  • If we decide that your medical condition doesn't meet the requirements for a fast decision, we will send you a letter that says so (and we'll use the standard deadlines instead. This letter will tell you that if your doctor asks for the fast decision, we'll automatically give a fast decision. The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you requested.

Step 2: Our plan considers your request for medical care coverage, and we give you our answer. (For Step 1, see the Filing a Grievance tab)

Deadlines for a "fast" coverage decision:

  • Generally, for a fast decision, we'll give you our answer within 72 hours.

  • If we don't give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal.

  • If our answer is yes to part or all of what you requested: We must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our decision, we'll provide the coverage by the end of that extended period.

  • If our answer is no to part or all of what you requested, we'll send you a written explanation.

Deadlines for a "standard" coverage decision:

  • Generally, for a standard decision, we'll give you our answer within 14 days of receiving your request.

  • We can take up to 14 more days ("an extended time period") under certain circumstances.

  • If we don't give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.

     

  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we'll provide the coverage by the end of that extended period.

     

  • If our answer is no to part or all of what you requested, we will send you a written explanation.

     

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

For More Information

If you have any questions about these procedures, call Member Service at 1-800-200-4255 (TTY: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Additional information on these processes is also included in your Evidence of Coverage.

  • If our plan says no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.

  • If you decide to make an appeal, it means you are entering Level 1 of the appeals process.

Medicare Advantage Part D Prescription Drug Plan Rights

This section describes your Part D prescription drug plan rights including:

  • Grievances

  • Coverage determinations

  • Exceptions

  • Appeal processes

For more detailed information, refer to Chapter 9 of the Evidence of Coverage.

Asking for Coverage Determinations

A coverage determination is a request for a Part D prescription drug benefit. If your doctor or pharmacist tells you that your prescription drug won't be covered, you or your doctor should contact us and ask for a coverage determination. You, your doctor, or your designated representative can request either a standard or an expedited coverage determination.

Request a Coverage Determination

When:

  • Your doctor or pharmacist tells you that we won't cover a medication in the amount or form prescribed to you

  • You're asked to pay a different cost-sharing amount than you think you're required to pay for a prescription medication

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

Call 1-800-200-4255 (TTY/TDD: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. There is no charge for calls made using this number.

Fax:

1-617-246-8506

Online:

Requests for coverage determinations and redeterminations may be submitted online or through email.

Mail:

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205

When you contact us, please have the following information available:

  • The name of the prescription(s) that you believe you need

  • The name of the pharmacy or doctor who told you that the prescription drug(s) is/are not covered

  • The date you were told that the prescription drug(s) is/are not covered

Resources

Members can download the 2018 Request for Medicare Prescription Drug Coverage Determination form from the Centers for Medicare & Medicaid Services (CMS).

Providers may download the Medicare Part D Coverage Determination Request form.

If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete this
Medicare Advantage Appointment of Representative form. The form must be signed by you and by the person whom you would like to act on your behalf. You must give our plan a copy of the signed form.

If we make a coverage determination and you are not satisfied with our decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage determination.

  • To start an appeal, you (or your representative or your doctor or other prescriber) must contact us.

  • Download the 2018 Request for Redetermination form to ask us for a redetermination (appeal).

When to Request an Appeal

When Blue Cross Blue Shield of Massachusetts or one of our plan doctors: 

  • Won't cover or pay for prescription medications you think we should cover

  • Won't give you a prescription medication you think should be covered

  • Reduces or cuts back on prescription medications you've been receiving

Standard Appeal Review Process

We must make a decision regarding your standard appeal within certain time frames designated by the Centers for Medicare & Medicaid Services (CMS). This means:

  • Every reasonable attempt will be made to resolve your complaint within seven (7) calendar days.

  • If we don't give you our decision within seven (7) calendar days, your request will automatically go to an independent review organization where a reconsideration or review will be made.

If we've agreed completely in your favor for a Part D drug you haven't received, we will:

  • Provide authorization for the drug within seven (7) calendar days after we received your appeal or sooner if your health requires it.

Expedited Appeal Review Process

After we receive an expedited appeal, we have up to 72 hours to give you a decision. If we don't give you our decision within 72 hours, your request will automatically go to an independent reviewer where a reconsideration or review will be made.

We may accept or decline your request for an expedited appeal as follows:

  • If we decline your request for an expedited appeal, we'll process your request through the standard appeal process. If you disagree with our decision not to expedite your request, you may file an expedited complaint.

  • If we accept your request for an expedited appeal with supporting documentation from your doctor, a decision will be made within 72 hours.

  • If we deny any part of your appeal, you or your designated representative have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and isn't part of the health plan.

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

Call 1-800-200-4255(TTY/TDD: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. There is no charge for calls made using this number.

Online:

Requests for coverage determinations and redeterminations may be submitted through email.

Fax:

1-617-246-8506

Mail:

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205

Exclusions from Your Prescription Coverage

By law, certain types of drugs or categories of drugs aren't covered under Medicare Part D. In those cases, Medicare exempts the drugs or drug categories from the exception and appeal processes. These drugs or categories are called "exclusions." They include:

  • Non-prescription drugs (also called over-the-counter drugs)

  • Drugs when used to promote fertility

  • Drugs when used for the relief of cough or cold symptoms

  • Drugs when used for cosmetic purposes or to promote hair growth

  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

  • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject

  • Drugs when used for treatment of anorexia, weight loss, or weight gain

  • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

However, in some cases you may use the coverage determination process to argue that a medication isn't statutorily excluded, isn't statutorily excluded from a specific indication, or is covered by the plan as a supplemental benefit. If you aren't disputing that a drug is excluded, but have a question or general complaint about an excluded drug not being covered by your Medicare Part D plan, your question or complaint will be processed as an inquiry or a grievance.

You may ask us to cover a prescription not listed on our Medicare Advantage formulary by requesting a formulary exception to waive coverage restrictions or limits on your medication. This list includes both brand-name and generic drugs covered by your plan.

In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary. For example, for certain medications, we limit the amount of medication that we will cover. If your prescription has a quantity limit, you may ask us to waive that limit and cover more.

When to request a formulary exception

When:

  • A prescription medication isn't listed on our Medicare drug formulary

  • You or your doctor want us to waive coverage restrictions or limits on your prescription medication

  • You or your doctor want us to provide a prescription medication at a lower cost-sharing amount (a tiering exception)

Exceptions also include providing medications at a lower cost-sharing amount (a tiering exception). The following are the tiering exceptions that can be requested:

  • If your drug is in Cost-Sharing Tier 2 (non-preferred generic) you can ask us to cover it at the cost-sharing amount that applies to drugs in Cost-Sharing Tier 1 (preferred generic). This would lower your share of the cost for the drug.

  • If your drug is in Cost-Sharing Tier 4 (non-preferred brand) you can ask us to cover it at the cost-sharing amount that applies to drugs in Cost-Sharing Tier 3 (preferred brand). This would lower your share of the cost for the drug.

  • You can't ask us to change the cost-sharing tier for any drug in Cost-Sharing Tier 3 (preferred brand) or Cost-Sharing Tier 5 (specialty medications).

More on Exceptions

  • Generally, we will only approve your request for an exception if the alternative drug included on the plan's formulary or the lower-tiered drug wouldn't be as effective in treating your condition and/or would cause you to have adverse medical effects.

  • Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception.

  • For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

  • If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

  • If we deny your request for an exception, you can ask for a review of our decision by making an appeal.

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

Call 1-800-200-4255 (TTY/TDD: 711), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. There is no charge for calls made using this numbe. There is no charge for calls made using this number.

Fax:

1-617-246-8506

Mail:

Blue Cross Blue Shield of Massachusetts
Member Service
P.O. Box 55007
Boston, MA 02205

Filing a Part D Prescription Drug Grievance

There are rules for making a formal complaint against Medicare HMO Blue and Medicare PPO Blue plans coverage situations. The rules described here are for grievances or complaints you might have about your Medicare Advantage Part D prescription drug coverage.

For information about our standalone Part D prescription plan, log on to Blue MedicareRx (PDP)SM.

You can file a grievance (complaint) for problems related to:

  • Quality of care

  • Waiting times

  • Member Service problems

When to file a grievance

  • You feel that you're being encouraged to leave or disenroll from your prescription drug plan

  • You have problems with the member service you receive

  • You disagree with our decision not to grant an expedited coverage determination or redetermination

Please reference your Evidence of Coverage for more examples of when to file grievances and other requests.

How to File a Grievance for Our Medicare Advantage Plans

You may submit your grievance orally or in writing within 60 days of the event.

Filing an oral grievance

Contact Member Service at 1-800-200-4255 (TTY: 711).

Filing a written grievance

Submit your grievance in writing within 60 days of the event or incident to:

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Grievance Coordinator
P.O. Box 55007
Boston, MA 02205

Fax:

1-617-246-8506

In your letter, please include:

  • Your name, address, and membership number

  • Your signature or that of a designated representative

  • The date your letter is signed

  • A description of the event and the date on which it occurred

You'll be notified of our decision about your grievance as quickly as your health condition allows, but generally no later than 30 calendar days after receiving your complaint. We may extend the time frame by 14 calendar days if you request an extension, or if more information is required to justify your grievance.

Medicare Complaint Form

You're now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services (CMS) values your feedback and will use it to continue to improve the quality of the Medicare program.
If you have any other feedback or concerns, or if this is an urgent matter, please call 
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

Contact Us:

Call 1-800-200-4255 (TTY: 711), as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.