Coverage Decisions, Appeals & Complaints

What is a coverage decision?

A decision about whether a medical service or drug prescribed for you is covered by the plan and the amount, if any; you are required to pay for the service or prescription.

How to submit a coverage decision about your medical care?

Coverage decisions are typically requested directly by your doctor. However, if you or your appointed representative needs to submit a request, have your doctor complete the appropriate form and mail or fax it to:

BlueCross BlueShield of Tennessee
BlueAdvantage Operations
1 Cameron Hill Circle Suite 005
Chattanooga, TN 37402-005

Fax: (423) 535-5498

For medical coverage decisions, please use the appropriate form below::

• HIT Advance Determination Fax Form
• General Advance Determination Fax Form
• Part B Drug Advance Determination Fax Form
• Cardiac Inpatient Advance Determination Fax Form
• Outpatient Therapy Advance Determination Fax Form
• Inpatient Rehabilitation Advance Determination Fax Form
• Durable Medical Equipment Advance Determination Fax Form
• Medical and Psychiatric Inpatient Advance Determination Fax Form

How to submit a Part D coverage decision?

Your doctor must submit a statement supporting your request. The doctor’s statement must indicate that the requested drug is medically necessary for treating your condition because none of the drugs we cover would be as effective as the requested drug or would have adverse effects for you. If the exception involves a prior authorization, quantity limit, or other limit we have placed on that drug, the doctor’s statement must indicate that the prior authorization, or limit, would not be appropriate given your condition or would have adverse effects for you. Mail or fax the written statement to:

CVS Caremark
Attn: Appeals Department
MC109
P.O. Box 52000
Phoenix, AZ 85072-2000

Fax: 1-866-884-9475

For drugs that require prior authorization, please have your doctor complete the appropriate form and mail or fax the completed form to:

CVS Caremark
Attn: Prior Authorization Department
1300 E. Campbell Road
Richardson, TX 75081

Fax: 1-888-836-0730

To download a Prior Authorization form, click here.

If no specific drug form is listed or you would like to send an inquiry for appropriate form, please complete the Clinical Prior Authorization Criteria Request Form and fax to the Prior Authorization Department at 1-888-836-0730.

Request for Medicare Prescription Drug Coverage Determination

To verbally file a coverage decision contact Member Services at:

1-800-841-7434
TTY/TDD users should call 1-888-423-9490.
8 a.m. to 9 p.m. ET, 7 days a week

Please note: From March 2 to October 14, you may be required to leave a message on holidays and weekends. Your call will be returned the next business day.

What is an appeal?

An appeal is something you do if you disagree with a decision to deny a request for healthcare services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving.

Important Information about Your Appeal Rights 

How to submit an appeal about your medical care?

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

BlueCross BlueShield of Tennessee
BlueAdvantage Operations
1 Cameron Hill Circle Suite 005
Chattanooga, TN 37402-005

Fax: (423) 535-5498

How to submit a Part D appeal?

If your request is denied, you have the right to appeal by asking for a review of the prior decision. You must request this appeal within 60 calendar days from the date of our first decision. For expedited requests please contact us by telephone or fax.:

CVS Caremark
Attn: Appeals Department
MC109
P.O. Box 52000
Phoenix, AZ 85072-2000

Fax: 1-866-884-9475

To verbally file an appeal contact Member Services at:

1-800-841-7434
TTY/TDD users should call 1-888-423-9490.
8 a.m. to 9 p.m. ET, 7 days a week

Please note: From March 2 to October 14, you may be required to leave a message on holidays and weekends. Your call will be returned the next business day.

What is a grievance?

A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

How to submit a grievance about your medical care or prescription drug coverage?

You may file a grievance with our Plan either by phone or in writing. Whether you call or write, you should contact Member Services right away. Grievances must be filed within 60 calendar days of the incident.

To verbally file a grievance, you or your doctor should contact Member Services at:

1-800-841-7434
TTY/TDD users should call 1-888-423-9490.
8 a.m. to 9 p.m. ET, 7 days a week

Please note: From March 2 to October 14, you may be required to leave a message on holidays and weekends. Your call will be returned the next business day.

To contact us in writing, mail or fax your completed Grievance Form  to: 

BlueCross BlueShield of Tennessee
BlueAdvantage Operations
1 Cameron Hill Circle Suite 005
Chattanooga, TN 37402-005

Fax: (423) 535-5498

How to appoint a representative?

If you would like to assign a representative to act on your behalf, both you and your representative must sign, date and complete an Appointment of Representative Form. This signed form must be filed with your coverage decision. 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 coverage decisions are filed during this time, your representative must file a photocopy of the signed representative form for each coverage decision. If your physician agrees to act as your representative and files a coverage decision for you, you cannot be charged by your physician for filing the coverage decision.

Mail or fax the form to:

BlueCross BlueShield of Tennessee
BlueAdvantage Operations
Appeals/Grievance Coordinator
1 Cameron Hill Circle Suite 0005
Chattanooga, TN 37402-0005

Fax: (423) 535-5270

More Detailed Information Is Available

This information is a brief overview of the BlueAdvantage medical and prescription drug coverage decision process. Please see Chapter 9 of your Evidence of Coverage for more information.

• BlueAdvantage Gold (PFFS) Evidence of Coverage
• BlueAdvantage Emerald (PPO) Evidence of Coverage
• BlueAdvantage Ruby (PPO) Evidence of Coverage
• BlueAdvantage Diamond (PPO) Evidence of Coverage

Contact Member Services to obtain an aggregate number of grievances, appeals, and exceptions files with this plan.

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