Expedited Review for Immediate or Urgently Needed Services

In place of the formal grievance review described above, you have the right to request an “expedited” review right away when your situ­ation is for immediate or urgently needed services. Blue Cross Blue Shield will review and respond to grievances for immediate or urgently needed services as follows:

When your grievance review con­cerns medical care or treatment for which waiting for a response under the grievance review time frames described above would seriously jeopardize your life or health or your ability to regain maximum function as determined by Blue Cross Blue Shield or your physician, or if your physician says that you will have severe pain that cannot be ade­quately managed without the care or treatment that is the subject of the grievance review, Blue Cross Blue Shield will review your grievance and notify you of the decision within 72 hours after your request is received.

When a grievance review is requested while the member is an inpatient, Blue Cross Blue Shield will complete the review and make a decision regarding the request before the patient is discharged from that inpatient stay. Coverage for those services in dispute will con­tinue until this review is completed.

A decision to deny payment for health care services may be reversed within 48 hours if the member’s attending physician certi­fies that a denial for those health care services would create a sub­stantial risk of serious harm to the member if the member were to wait for the outcome of the normal grievance process.

A grievance review requested by a member with a terminal illness will be completed within five working days of receiving the request. In this case, if the expedited review results in a denial for health care services or treatment, Blue Cross Blue Shield will send a letter to the member within five working days that explains the specific medical and scientific reasons for the denial and a description of alternative treatment, health care services, and supplies that would be covered and information about requesting a hearing. When the member requests a hearing, the hearing will be held within ten days (or within five working days if the attending physician determines after con­sultation with Blue Cross Blue Shield’s Medical Director and based on stan­dard medical practice that the effec­tiveness of the health care service, supply, or treatment would be materi­ally reduced if it were not furnished at the earliest possible date). You and/ or your authorized representative(s) may attend this hearing.

Reconsideration

Reconsideration is the first step in this appeals process. If you receive a letter denying payment for your dental services, you may request in writing that Blue Cross Blue Shield reconsider its decision by contacting:

Grievance Program

Blue Cross Blue Shield of

Massachusetts
One Enterprise Drive
Quincy, MA 02171-2126
Phone: 1-800-472-2689
Fax: 617-246-3616
Email: grievances@bcbsma.com

You must submit your reconsidera­tion request within 180 days of the adverse decision. Along with your let­ter, you should include any informa­tion that supports your request. Blue Cross Blue Shield will review your request and let you know the out­come of your reconsideration request within 15 calendar days after receipt of all necessary information.

Appeal

An appeal is the second step in this process. If Blue Cross Blue Shield continues to deny benefits for all or part of the original service, you may request an appeal within 60 days of receiving the reconsideration denial letter. Your appeal request should include any information that sup­ports your appeal. You may also inspect and add information to your Blue Cross Blue Shield case file to prepare your appeal. In accordance with Rhode Island state law, if you wish to review the information in your Blue Cross Blue Shield case file, you must make your request in writing and include the name of a dentist who may review your file on your behalf. Your dentist may review, interpret, and disclose any or all of that information to you. Once received by Blue Cross Blue Shield, your appeal will be reviewed by a dentist in the same specialty as your attending dentist. Blue Cross Blue Shield will notify you of the outcome of your appeal within 15 calendar days of receiving all neces­sary information.

External Appeal

For all grievances, you must first go through the formal internal grievance process as described above. In some cases, you are then entitled to a voluntary external review. Blue Cross and Blue Shield’s grievance review may deny coverage for all or part of a health care service or supply. When the denial is because Blue Cross and Blue Shield has determined that the service or supply is not necessary and appropriate, you have the right to an external review. You are not required to pursue an external review and your decision whether to pursue it will not affect your other benefits. If you receive a denial letter from Blue Cross and Blue Shield for this reason, the letter will tell you what steps you should take to file a request for an external review. A decision will be provided within ten days of the date the external reviewer receives your request for a review.

You also have the right to an expedited external review. You may request an expedited external review by contacting Blue Cross and Blue Shield at the telephone number shown in your denial letter. A final decision will be provided within 72 hours after the external reviewer receives your request for a review.

Expedited Appeal

If your situation is an emergency, you have the right to an expedited appeal at all three levels of appeal as stated above. An emergency requires emergency dental treatment to relieve acute pain or to control a dental condition that requires imme­diate care to prevent permanent harm to the member. You may request an expedited reconsideration or appeal by contacting Blue Cross Blue Shield at the telephone number shown in your letter. Blue Cross Blue Shield will notify you of the result of your expedited appeal within two working days or 72 hours, whichever is sooner, of its receipt. To request an expedited voluntary external appeal, you must send your request in writing to:

Grievance Program
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-2126
Phone: 1-800-472-2689
Fax: 617-246-3616
Email: grievances@bcbsma.com

Your request should state your reason(s) for your disagreement with the decision and include signed documentation from your dentist that describes the emergency nature of your treatment. In addition, you must also enclose a check payable to one of the following external appeals agencies: Masspro (your fee is $172.50) or the MAXIMUS Center for Health Dispute Resolution (your fee is $144.20).

Within two working days after the receipt of your written request and payment for the appeal, Blue Cross Blue Shield will forward your request to the external appeals agency along with Blue Cross Blue Shield’s portion of the

fee and your entire Blue Cross Blue Shield case file. The external appeals agency will notify you in writing of the decision within two working days or 72 hours, whichever is sooner, of receiving your request for a review.

External Appeal Final Decision

If the external appeals agency upholds the original decision of Blue Cross Blue Shield, this completes the appeals process for your case. But, if the external appeals agency reverses Blue Cross Blue Shield’s decision, the claim in dispute will be reprocessed by Blue Cross Blue Shield upon receipt of the notice of the final appeal decision. In addition, Blue Cross Blue Shield will repay you for your share of the cost for the external appeal within 60 days of the receipt of the notice of the final appeal decision.