• Appeals & Grievances

    Medical Appeals, Determination and Grievance Processes

  • Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan.

    How do I find out more information about my plan's grievance, determination and appeals process? 

    Please refer to chapter nine of your plan's Evidence of Coverage (EOC) for more information regarding grievance, determination and appeals processes. You may contact customer service with any questions or concerns including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with Premera Blue Cross Medicare Advantage Plans.

    What do I do if I have a problem or concern? 

    There are three types of processes for handling problems and concerns:

    • Organization Determinations
    • Appeals
    • Grievances

    What is an Organization Determination and when do I use it? 

    An Organization Determination is also called a "coverage decision". An Organization determination is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making an organization determination anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider - and perhaps change – this decision by making an appeal.

    To request an Organization Determination you, your doctor, or your representative may:

    • Call: 888-850-8526; TTY/TDD: 711 (This number requires special telephone equipment)
    • Fax: 855-339-8129
    • Write: Premera Blue Cross Medicare Advantage Plans; Attn: Appeals and Grievances Department, PO Box 4158, Portland, OR 97208-4158

    What is an Appeal and when do I use it? 

    If we make a coverage decision and you are not satisfied with our decision or part 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 of 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, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. These additional levels are explained in your Member Handbook/Evidence of Coverage.

    To file an Appeal you or your representative may:

    • Call: 888-850-8526; TTY/TDD: 711 (This number requires special telephone equipment)
    • Fax: 855-339-8129
    • Write: Premera Blue Cross Medicare Advantage Plans, Attn: Appeals and Grievances Department, PO Box 4158, Portland, OR 97208-4158

    What is a Grievance and when do I use it? 

    A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Member Handbook/Evidence of Coverage. If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 888-850-8526 (TTY line at 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Premera Blue Cross Medicare Advantage Plans Grievance Procedure. To use the formal grievance procedure, you may submit your written grievance to the Premera Blue Corss Medicare Advantage Appeals and Grievance Department. If you file a written grievance, or your complaint is related to quality of care and we have your consent to investigate, we will respond in writing to you.

    Appointing a Representative - You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service. If you are requesting Part C medical care or services, this statement must be sent to us at the address or fax number listed under "Part C Organization Determinations."

    Appointment of Representative Form 

    To file a Grievance you or your representative may:

    • Call: 888-850-8526; TTY/TDD: 711(This number requires special telephone equipment)
    • Fax: 855-339-8129
    • Write: Premera Blue Cross Medicare Advantage Plans; Attn: Appeals and Grievances Department, PO Box 4158, Portland, OR 97208-4158

    For quality of care problems, you may also complain to the Quality Improvement Organization (QIO)

    You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. Please refer to Chapter 2, Section 4, of your Evidence of Coverage for additional information about the Quality Improvement Organization in your state.

    Medicare Complaint Form - If you have complaints or concerns about Premera Blue Cross Medicare Advantage Plans and would like to contact Medicare directly please use the following link: Complaint Form 

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

    Appointing a Representative - You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service. If you are requesting Part C medical care or services, this statement must be sent to us at the address or fax number listed under "Part C Organization Determinations."

    Appointment of Representative Form 

    If you would prefer that someone else act on your behalf, please fill out this form, sign it and return it to us.

    • Mail: Premera Blue Cross Medicare Advantage Plans,Attn: Appeals and Grievance Department P.O. Box 4158 Portland, OR 97208-4158.
    • Fax: 855-339-8129.
    • Call: (if it is a fast appeal): 888-850-8526.
    • In person:
      Premera Blue Cross – Western Washington
      7001 – 220th ST. SW, Building 1
      Mountlake Terrace, WA 98043

    • Premera Blue Cross – Eastern Washington
      3900 East Sprague, Building 1
      Spokane, WA 99202

    Part D Coverage Determinations, Exceptions, Appeals and Grievances 

    How do I find out more information about my plan's grievance, determination and appeals process? 

    Refer to chapter 9 of your plan's Evidence of Coverage (EOC) for more information regarding grievance, determination and appeals processes.

    What are Coverage Determinations? 

    Coverage determinations are the first decisions made by the plan that determine whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.

    "Standard" Coverage Determination: For a "standard" coverage determination, the decision will typically be made within a 72-hour timeframe.

    "Fast" or "Expedited" Coverage Determination: You can ask for a "fast" coverage determination ONLY if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. "Fast" decisions only apply for Part D drugs that you have not yet received. A "fast" coverage determination is made typically within 24 hours.

    How Do I Request A Coverage Determination or Exception? 

    To check status or to request a "Standard", "Fast" or "Expedited" Coverage Determination: You, your appointed representative or your prescribing physician should contact us by telephone, fax or mail at the numbers or address below:

    • Call:888-850-8526
    • Fax: 800-249-7714
    • Write: Premera Blue Cross Medicare Advantage Plans; Attn: Appeals and Grievances Department, P.O. Box 4158, Portland, OR 97208-4158

    You, your prescriber or member representative may ask for a coverage decision via secure email by completing the Drug Coverage Determination Form, clicking on determinations@premera.com and attaching the form.

    What is an Appeal?  

    An appeal is the process that deals with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding you Part D prescription drug benefits or cost sharing associated with you Part D drug coverage.

    A "Standard" Appeal Decision means we have up to 7 calendar days from the time we receive your request to make a decision on a "standard" appeal.

    A "Fast" Appeal Decision means an appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.

    What is a Grievance? 

    A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits. Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint. If you request a "fast" grievance, a decision will be rendered within 24 hours.

    How Do I Request an Appeal or Grievance? 

    To check status or to request a "Standard,” "Fast" or "Expedited" Appeal or a Grievance: You, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand deliver at the numbers or address below:

    • Call: 888-850-8526
    • Fax: 855-339-8129
    • Mail: Premera Blue Cross Medicare Advantage Plans; Attn: Appeals and Grievances Department, P.O. Box 4158, Portland, OR 97208-4158

    You, your prescriber or member representative may ask for a retermination decision via secure email by completing the Drug Redetermination Form, clicking on redeterminations@premera.com and attaching the form.

    Appointing a Representative - You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service.

    Appointment of Representative Form - If you would prefer that someone else act on your behalf, please fill out this form, sign it and return it to us. In writing, to Premera Blue Cross Medicare Advantage Plans, Attn: Appeals and Grievances Department, P.O. Box 4158 Portland, OR 97208-4158.

    • Fax: 1-855-339-8129
    • Call: (if it is a fast appeal): 888-850-8526
    • Hand Deliver To
      Premera Blue Cross - Western Washington
      7001 - 220th St. SW, Building 1
      Mountlake Terrace, WA 98043

      Premera Blue Cross – Eastern Washington
      3900 East Sprague, Building 1
      Spokane, WA 99202

    Medicare Complaint Form - If you have complaints or concerns about Premera Blue Cross Medicare Advantage Plans and would like to contact Medicare directly please use the following link: CMS Complaint Form 

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

    Contact Information - If you need additional information or help, please call us at: Toll Free: 888-850-8526; TTY: 711.

    Other Resources to Help You: 

    Medicare Rights Center
    Toll Free: 888-HMO-9050

    Elder Care Locater
    Toll Free: 800-677-1116
    800-Medicare
    (800-633-4227)
    TTY: 877-486-2048

    Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice): You might leave our Plan because you have decided that you want to leave. There are also limited situations where we are required to end your membership. For example, if you move permanently out of our geographic service area.

    Voluntarily ending your membership

    There are only certain times during the year when you may voluntarily end your membership in our Plan. The key time to make changes is the Medicare Fall open enrollment period (also known as the "Annual Election Period"), which occurs from October 15 through December 7 for enrollments effective January 1, 2014. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help or who move, can make changes at other times. For more information on when you can make changes see the enrollment period table later in this section.

    If you want to end your membership in our plan during this time, this is what you need to do:

    • If you are planning on enrolling in a new Medicare Advantage plan: Simply join the new plan. You will be disenrolled from our plan when your new plan’s coverage begins on January 1.
    • If you are planning on switching to the Original Medicare Plan and joining a Medicare Prescription drug plan: Simply join the new Medicare Prescription drug plan. You will be disenrolled from our plan when your new plan's coverage begins on January 1.
    • If you are planning on switching to the Original Medicare Plan without a Medicare Prescription drug plan: Contact Customer Service for information on how to request disenrollment. You may also call 1-800-MEDICARE (1-800-633-4227) to request disenrollment from our plan. TTY users should call 711.Your enrollment in Original Medicare will be effective January 1.

    Until your membership ends, you must keep getting your Medicare services and prescription drug coverage through our Plan

    If you leave our Plan, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect earlier in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care and prescription drugs as usual through our Plan. If you happen to be hospitalized on the day your membership ends, generally you will be covered by our Plan until you are discharged. Call Customer Service for more information and to help us coordinate with your new plan. Until your prescription drug coverage with our Plan ends, use our network pharmacies to fill your prescriptions. While you are waiting for your membership to end, you are still a member and must continue to get your prescription drugs as usual through our Plan’s network pharmacies. In most cases, your prescriptions are covered only if they are filled at a network pharmacy including our mail-order-pharmacy service, are listed on our formulary, and you follow other coverage rules.

    We cannot ask you to leave the Plan because of your health

    We cannot ask you to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave our Plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.

    Involuntarily ending your membership.  

    If any of the following situations occur, we will end your membership in our Plan:

    • If you do not stay continuously enrolled in Medicare A and B
    • If you move out of the service area or are away from the service area for more than 6 months, you cannot remain a member of our Plan. And we must end your membership ("disenroll" you)". If you plan to move or take a long trip, please call Customer Service to find out if the place you are moving to or traveling to is in our Plan’s service area
    • If you knowingly falsify or withhold information about other parties that provide reimbursement for your prescription drug coverage
    • If you intentionally give us incorrect information on your enrollment request that would affect your eligibility to enroll in our Plan
    • If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of our Plan. We cannot make you leave our Plan for this reason unless we get permission first from Medicare
    • If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation
    • If you do not pay the Plan premiums, we will tell you in writing that you have a 90 day grace period during which you may pay the Plan premiums before your membership ends

    You have the right to make a complaint if we end your membership in our Plan

    If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.

    To check on your status or level, call:

    800-MEDICARE (800-633-4227), 24 hours per day, seven days per week. TTY/TDD users should call 877-486-2048.

  • For information on how to obtain an aggregate number of grievances, appeals and exceptions with Premera Blue Cross Medicare Advantage Plans, please contact Customer Service at 1-888-850-8526 (TTY: 711) 8 a.m. to 8 p.m., seven days a week (Pacific Time).
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