Blue Of California Appeals & Grievances Form printable pdf download

Blue Of California Appeals & Grievances Form

Appeals & Grievances Form

For use by Blue Shield’s Medicare Advantage Plan members and

Blue Shield’s Medicare Prescription Drug Plan members

Request for Appeal and/or Grievance

(see reverse for an explanation of a grievance and an appeal)

Member Name:

Member ID#:

Address:

Phone#:

Authorized Representative*:

APPEAL

Denied Service or Claim Number(s) you wish to appeal

Date(s) of Service(s):

Provider Name:

Total Amount in Dispute: $

Amount paid by Member (if any):$

Please explain your appeal request in clear, easy to read, detailed form. Please be sure

to provide any information you feel may be helpful including copies of any claims/bills,

medical records, or denial notices, if available:

Standard appeal (redetermination) request must be submitted in writing within 60 days

of the date on the notice of denial. Calling Member Services will initiate a standard

appeal, but it cannot be processed without your written request.

GRIEVANCE

Please explain your grievance or issue:

A grievance may be filed either orally or in writing within 60 days of the incident. Please

note that you may contact our Member Services Department at the telephone number

listed on your Blue Shield member ID card to file a grievance.

Signature:______________________________________

Date:_______________________

Member (or representative) signature (If representative, please fill out the attached

Appointment of Representative (AOR) Form)

Please return this form to the Blue Shield of California

Medicare Appeals & Grievance Department:

Mail Form to:

In Person:

P.O. Box 927

6300 Canoga Ave.

Woodland Hills, CA 91365-9856

Woodland Hills, CA 91367

or via facsimile at (916)350-6510

H0504_13_252 CMS Accepted 10012013

Blue Shield of California is an HMO and PDP

S2468_13_252 CMS Accepted 10012013

plan with a Medicare contract. Enrollment in

Blue Shield of California depends on contract

renewal.

Blue Of California Appeals & Grievances Form

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