Medicare Advantage Part C Medical Care Plan Rights

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.

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 including problems related to payment, and file a grievance regarding quality of care or other issues.

Asking for coverage decisions

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.

Contact Information for Coverage Decisions about your Medical Care and Services

PHONE

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.

TTY/TDD

1-800-522-1254. This number requires special telephone equipment. Calls to this number are free.

FAX

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

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

Calls to these numbers are free.

MAIL

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