Appeals & Grievances

  • We're here to help

    Sometimes you might need a formal process for dealing with a problem you are having.

    To file a grievance or complaint, you or your representative may call 800-722-1471  (TTY/TDD: 711).

    To file an appeal, you or your representative may use our member appeal form, or write a letter, and mail it to:

    Premera Blue Cross
    ATTN: Member Appeals
    PO Box 91102
    Seattle, WA 98111-9202

    Or fax our appeals department at (425) 918-5592.

    Common Forms

    Member appeal and authorization form
    Request an appeal of a decision and/or give your permission for another person to submit an appeal on your behalf.

    Member complaint form
    Send a complaint if you’re unhappy and want to share your feedback with Premera.

    Complaint and appeal rights
    Learn more about our appeal process.

    Appeal and when to use one

    If we make a coverage decision and you are not satisfied with part or all of our decision, you or your representative can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal." When you make an appeal, we review the coverage decision we have made to check to see if we were following all the benefits properly. When we have completed the review, we will give you our decision in writing. If we say no to all or part of your Level 1 Appeal, we will respond in writing with your next level right, if applicable. Appeal rights are available within your benefit booklet.

    Grievance and when to use one

    A grievance is any complaint about the quality of care you are receiving. If you have a complaint about any of the topics listed below, call customer service at 800-722-1471  (TTY/TDD: 711).

    • Customer service: For example, you think the customer service hours for your plan should be different.
    • Access to specialists: For example, you don't think there are enough specialists in the plan to meet your needs.
    • Information from your plan: For example, the company offering your plan is sending you materials you didn’t ask to get and aren’t related to your plan, or the plan’s notices don’t follow Medicare’s rules.
    • Problems with an appeal: For example, the plan isn’t following the appeals process or you disagree with the plan’s decision not to grant your request for a fast appeal or fast coverage determination.
    • Drug errors: Like being given the wrong drug or being given drugs that interact in a negative way.

    We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, customer service may ask you to send your complaint for review through our formal internal appeals process.

    The Medicare Beneficiary Ombudsman

    The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.

    Appointing a representative

    If you would like someone else to act on your behalf, in addition to the rest of the member appeal form, make sure to fill out section B. This form should be mailed to:

    Mail to:
    Premera Blue Cross
    ATTN: Member Appeals
    PO Box 91102
    Seattle, WA 98111-9202

    Or fax our appeals department at (425) 918-5592

    If you'd like to find out the total number of grievances, appeals, and exception requests Premera members have filed with us, please call 800-508-4722   (TTY/TDD: 711), Monday to Friday, 5 a.m. to 8 p.m. (Pacific).