General Appeals & Grievances

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

    • Organization determinations
    • Appeals
    • Grievances

    (For problems and concerns regarding pharmacy, please see the Part D Appeals & Grievances section.)

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

    To file a grievance, you or your representative may:
    Call: 888-850-8526 (TTY/TDD: 711)
    Fax: 855-339-8129
    Write: Premera Blue Cross Medicare Advantage Plans
    Attn: Appeals and Grievances Department
    PO Box 262527
    Plano, TX 75026

    General correspondence address:
    Premera Medicare Advantage Plans
    PO Box 262548
    Plano, TX 75026

    Fax: 800-390-9656

    Organization determination and when to use one

    An organization determination (coverage decision) is the initial decision we make about your benefits and coverage. It can also be about the amount we will pay for your medical services or drugs. 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.

    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, 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 Evidence of Coverage.

    Grievance and when to use one

    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 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/TDD: 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.

    To request an organization determination, appeal, or grievance:

    You, your doctor, or your representative can complete our secure, online Drug Coverage Redetermination Form.

    You can also make this request by completing the Drug Coverage Redetermination Form and faxing or mailing it to us.

    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.

    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, please fill out this form, sign it, and return it to us.

    Mail to:
    Premera Medicare Advantage Plans
    PO Box 262527
    Plano, TX 75026
    Fax: 800-390-9656

    For more about your plan's grievance, determination, and appeals process:

    Please refer to Chapter 9 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.

    If you'd like to find out the total number of grievances, appeals, and exception requests Premera members have filed with us, please call 888-850-8526 (TTY/TDD: 711).

    April 1 to September 30, Monday to Friday, 8 a.m. to 8 p.m.

    October 1 to March 31, 7 days a week, 8 a.m. to 8 p.m.