Appeals & Grievances

Part C Medical Coverage Determination, Grievances and Appeals

Members have a right to request an organization determination. (To keep things simple, we use “coverage decision” rather than “organization determination.”) If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

COVERAGE DETERMINATION

A coverage decision is any decision made by the plan regarding:

Receipt of, or payment for, a care item or service
The amount you pay for an item or service
A limit on the quantity of items or services

Any time that we make a decision about what we will cover and how much we will pay for your medical services or drugs, we are making a coverage decision.

Members have a right to request a coverage decision. If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

You can mail your coverage determination in writing or contact our member services team for more options to submit your Part C Medical coverage determination.

To request a coverage decision regarding medical care you or your representative may:

Mail:
CareFirst BlueCross BlueShield Preservice Review Department
1501 S. Clinton Street
8th Floor Cube 18001
Baltimore, MD 21224

To request a coverage decision regarding payment for medical care you already received you or your representative may:

Mail:
CareFirst BlueCross BlueShield Medicare Advantage Claims
P.O. Box 4495
Scranton, PA 18505

You can call Member Services to request information on a coverage determination or to request an expedited coverage determination verbally.

Concerns about the plan are important to us. For immediate attention to your grievance, you can call our Member Services to submit your grievance verbally for us to assist you in resolving your concerns.

Call:
855-290-5744

Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m. – 8 p.m., ET, Monday through Friday.

Under certain circumstances you can request an expedited coverage decision which is also called a “fast coverage decision.” A fast coverage decision means that we will make a decision no later than 72 hours after receiving the request.

To get a “fast coverage decision” you must meet both of the following requirements:

You are asking for coverage for medical care you have not yet received
Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If we determine that your request does not meet the criteria above, then it will be handled as a standard coverage decision

GRIEVANCES

A grievance is any complaint or dispute expressing dissatisfaction with any aspect of our operations, including our Medicare plans, Member Services, your provider or treatment facility.

You can submit a grievance at any time. You also have the right to withdraw a grievance.

You can file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.

The grievance will be sent to our Appeals and Grievance Department for handling. The plan's response may take 30 days or up to 44 days if more information is needed.

Call:
855-290-5744

Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m. – 8 p.m., ET, Monday through Friday.

You can also fax or mail your grievance in writing to us at:

Fax:
443-753-2298

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

You can also submit a complaint about your plan directly to Medicare.

Online:
Complete the Medicare Complaint Form

APPEALS

There are two types of appeals: standard appeals and expedited appeals.

1. Standard Appeals

You have the right to file an appeal if CareFirst BlueCross BlueShield did not approve or pay for services you believe should be covered or provided. This would be a standard appeal for benefits (pre-service appeal) or payment of a claim (payment appeal).

If a standard appeal is filed, we will send you a decision within:

7 days if the appeal is regarding a request for a pre-service Part B drug that a member wants to receive
30 days if the appeal is regarding a pre-service request for coverage of a benefit or service that a member wants to receive
60 days for an appeal for payment for a service or Part B drug that was already received.

2. Expedited Appeals

To file an expedited appeal, call Member Services at 855-290-5744 for assistance. You can also submit an expedited appeal in writing.

Fax for Clinical Pre-Service Expedited Appeals:
410-605-2566

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
P.O. Box 17636
Baltimore, MD 21298-9375

When can you submit a standard appeal?

Standard Payment Appeals

You can file a standard payment appeal within sixty (60) calendar days of the date of the notice of our initial determination. That timeframe may be extended if good cause exists.

All standard claims payment appeals must be submitted in writing to:

CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

Standard Pre-service Appeals

You can file a standard pre-service appeal within sixty (60) calendar days of the date of the notice of our initial determination. That timeframe may be extended if good cause exists.

All standard pre-service appeals for a service or Part B drug a member wants to receive must be submitted in writing to:

CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
P.O. Box 17636
Baltimore, MD 21298-9375

Expedited Appeals

If you believe waiting for a decision will seriously harm your health, you can ask that we process the appeal in an expedited manner. A CareFirst BlueCross BlueShield representative will contact you with a decision within 72 hours.

To file an expedited appeal, call Member Services at 855-290-5744 for assistance. You can also submit an expedited appeal in writing.

Fax for Clinical Pre-Service Expedited Appeals:
410-605-2566

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
P.O. Box 17636
Baltimore, MD 21298-9375

Need more information? Questions?

For more information about our process for appeals, grievances and coverage decisions, see Chapter 9 of your Evidence of Coverage (EOC).

To obtain the total number of grievances, appeals, and exceptions filed with the us, you should send a written request to: