If you have questions about the complaint or grievance process or your Explanation of Benefits statement, please call our BlueCare Service Representative at the number on the back of your identification card.
If you disagree with the determination of this claim, you may contact the Customer Service Department to attempt to informally resolve the matter. The individual member, or their authorized representative, who received the service(s) can contact Member Services if he/she also requires diagnosis information in order to identify the claim.
You have the right to file a formal complaint or grievance with the Plan within 180 days from the date of this notice. If your denial is related to medical necessity, appropriateness, health care setting or level of care, you may also request an external review following the final review of the appeal if your appeal is denied. For more information concerning the complaint and grievance procedures, see your member materials.
A copy of any rule, guidance, or protocol that was relied upon in making any adverse benefit determination is available upon request.
You can also receive assistance with the internal claims and appeals and external review processes by contacting the Pennsylvania Insurance Department Office of Consumer Services at 1-877-881-6388.
If you are a member of an ERISA group, you have the right to bring civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 once all administrative remedies have been exhausted.