Blue Of California Appeals & Grievances Form (Page 2 of 2) in pdf

Blue Of California Appeals & Grievances Form Page 2

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.

What is an Organization Determination?

An Organization Determination is an initial decision by Blue Shield 65 Plus or a person

such as your Personal Physician or Physician Group acting on the Plan’s behalf, to

approve or deny a payment for a service or a request for provision of service made by

you or on your behalf.

What is a Coverage Determination?

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.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the

prescription isn’t covered under your plan, that isn’t a coverage determination. You

need to call or write to your plan to ask for a formal decision about the coverage if you

disagree.

What is an Appeal?

An appeal is something you do if you disagree with a decision to deny a request for

health care services or coverage of prescription drugs, or denial of payment for services

or payment for drugs you already received. You may also make an appeal if you

disagree with a decision to stop services that you are receiving. For example, you may

ask for an appeal if our plan doesn’t pay for a drug, item, or service you think you

should be able to receive.

If we deny any part of your request for medical care service or payment of a service,

you may ask us to reconsider our decision. This is called an “Appeal” or a “request for

reconsideration.”

Additionally, if we deny any part of your request for Part D prescription drug(s) in our

Coverage Determination, you may ask us to reconsider our decision. This is called a

“request for redetermination.”

Please refer to your Evidence of Coverage for a complete description of how to file a

grievance and/or appeal.

Blue Of California Appeals & Grievances Form Page 2