As a member of the BCBSAZ Advantage health plan, you have the right to get appointments and covered services from the plan's network of providers within a reasonable amount of time. This includes the right to get timely services from our network specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
If you think that you are not getting your medical care or prescription drugs within a reasonable amount of time, or if we have denied coverage for your medical care or prescription drugs and you don't agree with our decision, you have the right to make a complaint. If you have any problems or concerns about your covered services or care, Chapter 9 - What to do if you have a problem or complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do - ask for a coverage decision, make an appeal, or make a complaint - we are required to treat you fairly.
What is a grievance?
A grievance is a complaint about the way the BCBSAZ Advantage, a network provider, or a network pharmacy treats you. For example, you may file a grievance if you have a complaint about:
- A doctor, hospital, or provider.
- Your health or drug plan.
- The quality of your care.
- Your dialysis or kidney transplant care.
- Durable medical equipment.
- Any other issue about BCBSAZ Advantage or our network providers and pharmacies.
You, or your representative, may either file a standard or expedited (fast) grievance in writing or by telephone. See "How do I file a grievance or request an appeal" below.
However, if you have a complaint about a plan's refusal to cover or pay for a service, supply, or prescription, you will need to file an appeal.
What is an appeal?
An appeal is a request from you, your representative, or your doctor if you disagree with a coverage or payment decision made by BCBSAZ Advantage. For example, you can request an appeal if BCBSAZ Advantage denies:
- A request for a health care service, supply, item, or prescription drug that you think you should be able to get.
- A request for payment of a health care service, supply, item, or prescription drug you already got.
- A request to change the amount you must pay for a health care service, supply, item, or prescription drug.
You can also request an appeal if BCBSAZ Advantage stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.
You, your representative, or your doctor must file a written standard or expedited (fast) request, or you may file a request by telephone. See "How do I file a grievance or request an appeal" below.
If you decide to file an appeal, you can ask your doctor, supplier, or other health care provider for any information that may help your case. Keep a copy of everything you send to Medicare or your plan as part of your appeal.
How long do I have to file a grievance or an appeal?
You may file a grievance or an appeal no later than 60 calendar days after the date the event causing the grievance took place or the date the service or payment you requested was denied.
Can someone help me file a grievance or request an appeal?
Yes, you can appoint someone as your representative to assist you in filing a grievance or requesting an appeal. Click here for complete information on how to appoint a representative.
How do I file a grievance or request an appeal?
You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call the Member Services Department
How long will it take to process my grievance or appeal?
BCBSAZ Advantage will process a standard grievance as quickly as your case requires based on your health status, but not later than 30 calendar days, unless the time frame is extended.
We will process an expedited grievance if you complain about our refusal to grant a request for an expedited organizational determination or appeal or about our decision to extend the time frame for us to make a decision.
For medical claims appeals, BCBSAZ Advantage will process appeals in the following time frames:
- An expedited (fast) reconsideration (appeal) for requested health care services within 72 hours;
- A standard appeal for requested health care services within 30 calendar days; and
For drug appeals, BCBSAZ Advantage will process appeals in the following time frames:
- An expedited (fast) redetermination (appeal) for requested prescription drug services within 72 hours;
- A standard appeal for requested prescription drug services within 7 calendar days; and
- A request for redetermination of payment for prescription drug services within 14 calendar days.
- Medicare.gov is the official U.S. Government site for Medicare. You may find additional information about your Medicare rights, filing a grievance, requesting an appeal, Medicare forms and many other useful resources below:
- Your Medicare Rights
- Rights & Protections for Everyone with Medicare
- Your Rights in Medicare Health Plans
- Your Rights in Medicare Drug Plans
- How to file a complaint (also called a "grievance") with Medicare
- How to file an appeal with Medicare
- Medicare Appeal Forms (including Appointment of Representative - CMS-1696)
- Medicare Ombudsman Office Website
Need help filing complaint?
Medicare beneficiaries may also call 1-800-MEDICARE (633-4227) 24 hours per day, 7 days a week, to speak with a Medicare representative. TTY hearing impaired users call 1-877-486-2048.
Social Security Resources
You may also call Social Security at 1-800-772-1213. TTY hearing impaired users call 1-800-325-0778, Monday-Friday, 7 a.m. to 7 p.m.