Member Rights - Appeals

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.

How to File an Appeal

Complete the Member Form or Physician Form . Supporting statements from your physician are required. Mail or fax to:

Pharmacy Review
P.O. Box 12485
Birmingham, AL 35202-2485

Fax: (205) 220-9575

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

1-888-311-7508
TTY/TDD users should call 1-800-257-3384
8:00 a.m. to 8:00 p.m. Central Time, 7 days a week

From March 1 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 . 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:

Pharmacy Review
P.O. Box 12485
Birmingham, AL 35202-2485

Fax: (205) 220-9575

More Detailed Information Is Available

This information is a brief overview of the BlueAdvantage medical appeals process. Please see Chapters 6 and 7 of your Evidence of Coverage for more information.