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.
If we make a coverage decision and you are 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 check 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 is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through three more levels of appeal.
You can call us at Member Service at the phone number listed below.
To get free help from an independent organization that is not 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."
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.
If we are 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 will 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.
When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will 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 will tell you in writing.
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.
Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205