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This section describes your Part C medical plan rights including grievances, coverage decisions, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.
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 including problems related to payment, and file a grievance regarding quality of care or other issues.
A coverage decision is a decision we make about your benefits and coverage or about the amount we will 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 will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Call 1-800-200-4255, 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. Calls to this number are free.
1-800-522-1254. This number requires special telephone equipment. Calls to this number are free.
For emergency inpatient acute hospital admissions: 1-866-577-9678.
For all other requests:
Calls to these numbers are free.
Blue Cross Blue Shield of Massachusetts
P.O. Box 55007
Boston, MA 02205