Review and Response from Blue Cross Blue Shield
The review and response for Blue Cross Blue Shield’s formal grievance review will be completed within 30 calendar days. Every reasonable effort will be made to speed up the review of grievances that involve health care services that are soon to be obtained by the member. (When the grievance review is for services you have already obtained and it requires a review of your medical/ dental records, the 30-day response time will not include the days from when Blue Cross Blue Shield sends you the authorization form to sign until it receives your signed authorization form if needed. If Blue Cross Blue Shield does not receive your authorization within 30 calendar days after you are asked for it, Blue Cross Blue Shield may make a final decision about your grievance without that medical/dental information.)
Note: If your grievance review began after an inquiry, the 30-day response time will begin on the day you tell Blue Cross Blue Shield that you disagree with Blue Cross Blue Shield’s answer and would like a formal grievance review.
Blue Cross Blue Shield may extend the time frame to complete a grievance review, with your permission, in cases when Blue Cross Blue Shield and the member agree that additional time is required to fully investigate and respond to the grievance. A grievance that is not acted upon within the specified time frames will be considered resolved in favor of the member.
Once the grievance review is completed, Blue Cross Blue Shield will let you know in writing of the decision or the outcome of the review. If Blue Cross Blue Shield continues to deny coverage for all or part of a health care service or supply, Blue Cross Blue Shield’s response will explain the reasons. It will give you the specific medical and scientific reasons for the denial, refer to the specific plan language on which the denial is based, and provide description of alternative treatment, health care services, and supplies that would be covered. The response will also inform you that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim and copies of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination. Finally, the response will describe the claims procedures for any additional level of appeal and the applicable time limits, external review rights, the right to obtain information about the claims procedures, and a statement of your right to bring a civil action under Section 502(a) of ERISA regarding the grievance.
Blue Cross Blue Shield will maintain a record of all formal grievances, including the response for each grievance review, for up to seven years.