Forms & Policies

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General Forms and Policies 

Coverage Decisions, Appeals and Complaints

  • Coverage decision: decisions we make about whether a service is covered by the plan and the amount, if any, we are required to pay for the service. Coverage decisions are also called organization determinations.
  • Appeal: if you are not satisfied with the outcome of a coverage decision, you can appeal the decision by requesting a plan reconsideration. 
  • Grievance: any complaint other than one that involves an Organization Determination.
Coverage Determinations and Appeals — Medicare Advantage

Coverage Determination Details

When you ask for a decision about a Medicare Advantage health benefit or the amount we will pay for a service, you are requesting a coverage decision, which is also called an organization determination. If your health care provider tells you that we will not cover a service, or if you are charged more than you think your copayment or coinsurance should be, you or your provider may ask us for an organization determination.

The following are examples of when you can ask us for an organization determination:

  • You are requesting payment for a service furnished by a provider that you believe should have been reimbursed by the health plan
  • You are requesting payment for out-of-the-area renal dialysis services
  • You have been told we are reducing or discontinuing a previously authorized service
  • You are requesting payment for emergency services

When you request an organization determination, you will receive a response from us within:

  • 72 hours for a pre-service expedited decision
  • 24 hours for a Part B drug expedited decision
  • 14 days for a standard decision
  • 72 hours for a Part B drug standard decision
  • 60 days for payment

The process for requesting an organization determination is discussed in more detail in Chapter 9 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints).” If you or your provider do not agree with the outcome of the initial organization determination, you or your provider may appeal the decision by requesting a reconsideration. This is also called a level 1 appeal.

Coverage Appeals

You can file an appeal if you do not agree with our organization determination. You must make your appeal request within 60 calendar days from the date on the written notice we send to answer your request for an organization determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

You will receive a response from us on a level 1 appeal within:

  • 72 hours for an expedited decision
  • 30 days for pre-service standard appeal
  • 7 days for a Part B standard appeal
  • 60 days for payment

If our plan says no to your level 1 appeal, we will forward the case file to the Independent Review Organization for a level 2 appeal. You will receive a response on a level 2 appeal from the Independent Review Organization within:

  • 72 hours for an expedited appeal
  • 30 days for pre-service standard appeal
  • 7 days for a Part B standard appeal
  • 60 days for payment

If the Independent Review Organization says no to your appeal, you may be able to continue to a third level appeal with an Administrative Law Judge (ALJ). The dollar value of the coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at level 2 is final. The notice you get from the Independent Review Organization will tell you if the dollar value of the coverage you are requesting is high enough to continue with the appeals process.

If the ALJ denies your appeal, then your case may be reviewed by the Medicare Appeals Council (MAC). If your case is reviewed and denied by the MAC, then the notice you get will tell you whether the rules allow you to go on to the fifth and final level of appeal. If the rules allow you to go on, the written notice will tell you who to contact and what to do next if you choose to continue with your appeal. The fifth level appeal is reviewed by a judge at the Federal District Court. This is the last stage of the administrative appeals process.

You, your prescribing health care provider or another person you name can file an appeal for you. The person you name would be your appointed representative. If you want some other person to act for you, you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.

Coverage Determinations and Appeals — Medicare Prescription Drug Plans (Part D)

Coverage Determination Details

When you ask for a decision on your Part D prescription drug benefit, you are requesting a coverage determination.

If your health care provider or pharmacist tells you that we will not cover a prescription drug, or if you are charged more than you think your copayment or coinsurance should be, you or your provider may ask us or a coverage determination.

To request a coverage decision or reconsideration:

Call 1-855-204-2744 (TTY 711). Fax your request to 1-803-264-9581. Email your request to medhelp@bcbssc.com. Download a reconsideration request form. You can name another person to act as your “representative” and ask for a coverage decision or reconsideration on your behalf, such as a friend, relative, doctor or other prescriber. To have a representative act on your behalf, both you and the representative must sign the Appointment of Representative Form (PDF).

The following are examples of when you can ask us for a coverage determination:

  • If there is a limit on the quantity (or dose) of a drug and you disagree with the limit
  • If there is a requirement that you try another drug before we will pay for the drug you are asking for
  • If the copayment for a drug is higher than expected
  • If the drug is listed as non-formulary

When you request a coverage determination, you will receive a response from us within:

  • 72 hours for a "standard" decision
  • 24 hours, if you have asked for a "fast" decision, also called an expedited determination

The process for requesting a coverage determination is discussed in more detail in Chapter 7 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints).”

If you or your provider do not agree with the outcome of the initial coverage determination, you or your provider may appeal the decision by requesting a coverage redetermination. This is also called a level 1 appeal.

Coverage Appeals

You can file an appeal if you do not agree with our coverage determination. You must make your appeal request within 60 calendar days from the date on the written notice we send to answer your request for a coverage determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

You will receive a response from us on a level 1 appeal within:

  • Seven calendar days for a "standard" decision
  • 72 hours, if you have asked for a "fast" decision

If our plan says no to your level 1 appeal, the written notice we send you will include instructions on how to make a level 2 appeal with the Independent Review Organization. These instructions will tell who can make this level 2 appeal, what deadlines you must follow and how to reach the review organization.

If the Independent Review Organization says no to your appeal, you may be able to continue to a third level appeal with an Administrative Law Judge (ALJ). The dollar value of the coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at level 2 is final. The notice you get from the Independent Review Organization will tell you if the dollar value of the coverage you are requesting is high enough to continue with the appeals process.

If the ALJ denies your appeal, then your case may be reviewed by the Medicare Appeals Council (MAC). If your case is reviewed and denied by the MAC, then the notice you get will tell you whether the rules allow you to go on to the fifth and final level of appeal. If the rules allow you to go on, the written notice will tell you who to contact and what to do next if you choose to continue with your appeal. The fifth level appeal is reviewed by a judge at the Federal District Court. This is the last stage of the administrative appeals process.

You, your prescribing health care provider or another person you name can file an appeal for you. The person you name would be your appointed representative. If you want some other person to act for you, you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.

Filing a Grievance

A grievance is any complaint other than one that involves an organization determination. You may file a grievance either orally or in writing, no later than 60 days after the event or incident that led to the grievance. You may file a grievance for a variety of reasons, including:

  • Feeling that you are being encouraged to leave (dis-enroll from) your Medicare Health Plan.
  • Problems getting an appointment.
  • Disrespectful or rude behavior by providers or staff.
  • Cleanliness or condition of a hospital or doctor's office
  • Disagreeing with our decision not to give you a "fast" organization determination or appeal

You will receive a response within:

  • 24 hours if your grievance involves a refusal to give you a "fast" organization determination or appeal.
  • 30 calendar days for all other grievances. We may extend the timeline by up to 14 calendar days if you ask for an extension, or if we justify a need for additional information and the delay is in your best interest.

If you have a grievance, you can call Customer Service at 1-855-204-2744 (toll free), or TTY 711, during the hours of operation.

  • From October 1 to March 31, the Customer Service hours are 8 a.m. to 8 p.m. Eastern Time, seven days a week.
  • From April 1 to September 30, the Customer Service hours are 8 a.m. to 8 p.m. Eastern Time, Monday through Friday. Our automated phone system handles calls received after 8 p.m. and on Saturdays, Sundays and holidays.

You can also mail your grievance to:
BlueCross BlueShield of South Carolina Medicare Advantage
P.O. Box 100191
Columbia, SC 29202-3191

Complaints about Quality of Care

If you have a complaint about the quality of care you received, such as about getting discharged from the hospital too soon, you may also complain to the Quality Improvement Organization (QIO).

Acentra Health BFCC-QIO
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
Phone: 1-888-317-0751 TTY: 777
Web: www.acentraqio.com

For a complete description of your appeal and grievance rights, please see your Evidence of Coverage.

Contact Medicare

If you have questions, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day, 7 days a week.

While we encourage you to contact Customer Service first when you have a grievance, you can also tell Medicare about your grievances directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.

 

 

Disclaimer

Last Updated: November 1, 2024

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BlueCross BlueShield of South Carolina is a Medicare Advantage PPO plan with a Medicare contract. BlueCross Rx Value is a stand-alone prescription drug plan with a Medicare contract. Enrollment in BlueCross Total, BlueCross Total Value, BlueCross Blue Basic, or BlueCross Rx Value depends on contract renewal. 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. 

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of South Carolina Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. Free language interpretation services are available for those who cannot read or speak English.