Form 34-730web - Bluecross Blueshield Of Kansas Appeal Form
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1YOUR APPEAL RIGHTS AND APPEAL FORM
If you receive your health benefits coverage through an employer-sponsored plan and your employer is not a
governmental entity or religious organization, your claim appeal rights are likely governed by the Employee Retirement
Income Security Act (ERISA). If you receive your health benefits coverage through any other arrangement, you have the
same appeal rights as a matter of contract.
To appeal a claim that has been denied in whole or in part for which you have financial responsibility you must do the
following:
1. Make your appeal in writing by attaching the
If you are covered by a health plan subject to ERISA,
you have the right to pursue judicial review in federal
appropriate Explanation of Benefits (EOB) and circling
or state court under Section 502(a) of ERISA only
the claim that you want to appeal.
after exhausting the above appeal procedures. This
2. Tell us why you disagree with the denial:
exhaustion requirement also applies to non-ERISA
coverage and plans, i.e. you must complete all
applicable appeals indicated above prior to initiating
any legal action concerning the denial of your claim.
3. You have the right to documents, free of charge,
6. If you have authorized someone else to make this
used in making the claim determination including any
appeal on your behalf, you must give us the following
guidelines or rules referred to in the denial. Please list
information:
the specific documents you want:
Authorized person’s name:
Address for mailing notices:
4. List any documents you have attached for
consideration in your appeal:
Telephone Number (
)
5. BCBSKS must receive your first level appeal within 180
Fax Number (
)
days of the adverse decision. BCBSKS must make an
initial appeal determination within 30 days of receiving
your written appeal. Group members also have the
Signature
right to a second level of appeal if BCBSKS receives
Date
the written request on appeal within 90 days of the first
appeal determination if such rights are included in your
Identification Number
member certificate. BCBSKS must make the second
Telephone Number (
)
appeal determination within 30 days of receiving your
written request for second level appeal.
Fax Number (
)
Mail your appeal to: Blue Cross and Blue Shield of Kansas, 1133 SW Topeka Blvd., Topeka, KS 66629
If you have questions about your claim or the appeals process please call: Blue Cross and Blue Shield of Kansas
Customer Service Center (800) 432-3990.
Esta correspondencia ciá disponible en español, llame por favor el centro del servicio de atención al cliente.
如果您居住在加利福尼亚州的旧金山市，而此信件为中文。请致电客户服务中心。
Applicable to administrative services only groups: Blue Cross and Blue Shield of Kansas provides administrative
claims payments only and does not assume any financial risk or obligation with respect to claims. Please consult your
contract, certificate, or benefit description to determine whether this applies to you.
Other insurance resources:
Kansas Insurance Department, Customer Assistance Division: 420 SW 9
St., Topeka, KS 66612
th
Phone: (785) 296-3071 – Toll Free: (800) 432-2484 – E-mail: –
Employee Benefits Security Administration (EBSA) may be contacted at 1-866-444-EBSA (3272) or
34-730WEB (01/14)
An Independent Licensee of the Blue Cross and Blue Shield Association.
CLEAR DATA
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