Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan.
There are three types of processes for handling problems and concerns:
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 any time 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:
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:
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: 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 Cross 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: 711)
Write: Premera Blue Cross Medicare Advantage Plans, Attn: Appeals and Grievances Department, PO Box 4158, Portland, OR 97208-4158
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 to: Premera Blue Cross Medicare Advantage Plans, Attn: Appeals and Grievances Department, P.O. Box 4158 Portland, OR 97208-4158.
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.
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:
You, your prescriber or member representative may ask for a coverage decision via secure email by completing the Drug Coverage Determination Form, clicking on firstname.lastname@example.org, and attaching the form.
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.
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 or fax at the numbers below, or mail or hand deliver to the address below:
You, your prescriber or member representative may ask for a redetermination decision via secure email by completing the Drug Redetermination Form, clicking on email@example.com, and attaching the form.
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).
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, 2015. 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 any of the following situations occur, we will 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, 7 days per week. TTY/TDD users should call 877-486-2048.
888-868-7767 (TTY: 711)
7 days a week, 8 am to 8 pmOctober 1-February 14
Monday-Friday, 8 am to 8 pmFebruary 15-September 30
Mail your enrollment applications to:
PO Box 4198Portland, OR 97208-4198
General correspondence address:
PO Box 4196Portland, OR 97208-4196
Monday through Friday, 8 a.m. to 8 p.m.
We're ready to enroll you by phone or answer your questions.
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