Your Rights Under This Plan

Medical Grievances, Appeals and Advance Determinations

What is a Grievance?

If you have a problem with any of our medical policies and procedures, you may file a grievance. You cannot be dropped from the plan for making a complaint.

How to File a Grievance : 

You or your doctor may call Customer Service to verbally file a grievance or to check on the status of a grievance:

1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
8 a.m. to 9 p.m. ET, 7 days a week

From March 2 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.

Complete the Grievance Form (PDF). Supporting statements from your physician are required. Mail or fax to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 535-5270

What is an Appeal?

If we deny a claim or service, we will explain why. If you disagree with our decision regarding the handling of your claim or a denial of a service or prescription drug, you have the right to file an appeal. Your claim will be reviewed again. If you are still not satisfied with the decision, your appeal will be reviewed by an independent organization that works for Medicare.

• Important Information About Your Appeal Rights (PDF)

How to File an Appeal 

Complete the Appeal Form (PDF). Supporting statements from your physician are required. Mail or fax to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 535-5270

You or your doctor may call Customer Service to check on the status of an appeal:

1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
8 a.m. to 9 p.m. ET, 7 days a week

From March 2 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.

Appointing a Representative to Act on Your Behalf 

You may assign someone such as a relative, friend, advocate, an attorney or any physician to act as your representative and file an appeal for you. A representative may:

• Obtain information about your claim to the extent consistent
  with current Federal and state law;
• Submit evidence;
• Make statements of fact and law; and
• Make any request, or give or receive any notice about the appeal
  proceedings.

If you want to assign a representative to ask for an appeal for you, both you and your representative must sign, date and complete the Appointment of Representative Form (PDF). This signed form must be filed with your appeal. Unless you decide you no longer want to have a representative, the form will be good for one year after the date you and your representative sign the form. If future appeals are filed during this time, your representative must file a photocopy of the signed representative form for each appeal. If your physician agrees to act as your representative and files an appeal for you, you cannot be charged by your physician for filing the appeal.

BlueAdvantage members only need to complete the first three sections of this form. Mail or fax the form to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 535-5270

More Detailed Information is Available 

This information is a brief overview of the BlueAdvantage medical grievance and appeals process. Please see sections 4 and 5 of your Evidence of Coverage for more information.

How to Request an Advance Determination

Advance determinations (d) are usually requested directly by your physician. However if you need to submit a request yourself, have your doctor complete the appropriate form and mail or fax it to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Medical Management
P.O. Box 180205
Chattanooga, TN 37402
Fax: 1-888-535-5243

For medical advance determinations, please use the appropriate form below:

• Skilled Nursing Facility / Inpatient Rehabilitation (PDF)
• Home Infusion Therapy (PDF)  
• Durable Medical Equipment (PDF) 
• Part B Drug (PDF)
• Inpatient (PDF)
• Cardiac Inpatient (PDF)
• General (PDF)

Pharmacy Coverage Determinations/Exceptions, Grievances and Appeals

What is a coverage determination?

A coverage determination is a decision as to whether or not we provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations also include exception requests. These will be reviewed within 72 hours of receiving all the information required to review your request.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with BlueAdvantage or one of our network pharmacies that does not relate to coverage for a prescription drug. You may file a grievance with us either orally or in writing no later than 60 days after the event or incident that precipitates the grievance. We will respond to your grievance within 30 days after receiving your request.

What is an appeal?

An appeal is the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. You must request an appeal within 60 days from the date of the notice of the coverage determination. Appeals are reviewed and determinations returned within 7 days upon receiving all necessary information.

What if I need my request expedited?

If you or your health care provider believe that waiting for a decision under the standard time frame may place your life, health, or ability to regain maximum function in serious jeopardy, an expedited appeal may be requested. Once all necessary information is received, your request will be reviewed and a determination sent to you and all necessary parties within 24 hours.

How to submit a grievance, coverage determination or appeal?

The first step to filing your grievance, appeal, or seeking a coverage determination is to call:

1-800-841-7434

TTY/TDD for Hearing Impaired: 1-888-423-9490
8 a.m. to 9 p.m. ET, 7 days a week

From March 2 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.

If you would like to submit a written request for an appeal, forrmulary exception, tiering exception, prior authorization or reimbursement for a covered prescription drug you paid for out of pocket :

Please print, complete and sign this form.

Member Form (PDF)
Physician Form (PDF)

Send the signed and completed form to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 535-5270

How to find additional information about grievances, coverage determinations, and appeals?

You can find additional information about our pharmacy grievance, coverage determination (including exceptions), and appeals process by reviewing sections 4 and 5 of your plan's Evidence of Coverage.

Medicare Advantage Plans Contract for One Full Year

All health plans with a Medicare contract agree to stay with the Medicare program for a full year at a time. The availability of coverage from a particular plan beyond the current year is not guaranteed.

If your plan leaves the Medicare program, or Medicare does not renew your plan’s contract, you will not lose your Medicare coverage. You will receive notification 90 days in advance along with information about your other Medicare coverage options.

Disenrollment

If you choose to enroll in a different plan during the Open Enrollment Period or at the next Annual Coordinated Election Period, you will automatically be disenrolled from your current plan. 

There are several situations that may cause you to be disenrolled by your plan:

• You move out of your plan’s service area.
• Your plan’s Medicare contract ends.
• Your plan’s service area changes and you do not live in the revised service area.

Disenrollment due to any of the above reasons entitles you to a Special Enrollment Period. You will be given other Medicare options and the opportunity to enroll in a new plan.

You can also be disenrolled by your plan if:

• You do not pay your premiums in a timely fashion.
• You do not abide by the terms and conditions of your plan.
• You knowingly provide false information on your enrollment application or permit another individual to use your member ID card to receive medical services under the plan.

In any of the above cases you will be notified of your disenrollment, the effective date and the reason. You have a right to a hearing under our grievance procedures. See the Evidence of Coverage you receive when you enroll for more information.

Finally, you can be disenrolled if:

• You lose your entitlement to either Medicare Part A or Part B.

If you lose your entitlement, you will be notified by the Centers for Medicare & Medicaid Services. Your Medicare Advantage plan will automatically end on the date your entitlement ends.