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You have a right to ask us to provide or pay for items or services you think should be covered, provided or continued. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. When a coverage decision involves your medical care, it is called an "organization determination."
Your physician or an office staff member may request a medical prior authorization by calling customer service toll free at:
Blue Cross Medicare Advantage Plans: 1-877-774-8592 (TTY 711)
You can also fax the request to: 1-855-874-4711
Or mail the request to:
Blue Cross Medicare Advantage
c/o UM Intake
P.O. Box 4288
Scranton, PA 18505
If you want to know if we will cover a medical service before you get it, you can ask us to make a coverage decision for you. A coverage decision is made about your benefits and coverage or about the amount we will pay for your medical services or drugs. You or your doctor can ask for a coverage decision if you aren’t sure if your plan covers a medical service or if care is refused for a medical service you think that you need. If you disagree with this coverage decision, you can make an appeal (see below contact information ‘Filing a Medical Appeal’).
Call, mail or fax your request to the plan to authorize or provide coverage for the medical care you want. You, your doctor, or your appointed representative can do this. See below for contact information.
Phone:
1-877-774-8592 (TTY 711)
Fax Number:
1-855-674-9185
Mailing Address:
Blue Cross Medicare Advantage
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505
Appeals: You can ask for an appeal: If coverage or payment for an item or medical service is denied that you think should be covered.
Expedited Appeals: You can ask for an expedited (fast) appeal if:
Grievances: You can file a grievance if you have a complaint about the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above. If you have coverage issues related to medical or pharmacy services, or if you or your appointed representative wishes to file a grievance, please contact customer service.
You may also contact Blue Cross Medicare Advantage if you want information about the number of appeals, grievances, or exceptions filed with the plan.
These issues may be reasons to file a grievance.
If you have a grievance, we ask you to first call customer service at 1-877-774-8592 (TTY 711).
You can also send us your grievance in writing to:
Blue Cross Medicare Advantage Plan
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505
Fax Number:
1-855-674-9189
You must file a grievance with us no later than 60 days after the event or incident in question.
We try to resolve any complaint you have over the phone. If customer service cannot resolve your concern over the phone, we have a formal process to review your complaints. We have made this process easy to follow so you will get a timely response. If your concern is not resolved at the time of your first phone call, it will be sent on to a grievance coordinator to be resolved. Generally, you will be sent a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after we get it.
If your grievance involves the quality of the care you received, you will get a written response. We may add to the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for more information and the delay is in your best interest. When we add to the deadline, we will immediately let you know the reason(s) for the delay in writing.
If you or your appointed representative wants to file a grievance, please contact Customer Service at 1-877-774-8592 (TTY 711).
You may file a grievance in writing by sending a letter telling us about your grievance:
Blue Cross Medicare Advantage
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505
Fax Number:
1-855-674-9189
You will get a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after we get your complaint. We may add to the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for more information and the delay is in your best interest. When we add to the deadline, we will immediately let you know the reason(s) for the delay in writing.
Last Updated: 12312020
Y0096_WEBOKMM21
Last Updated: 12312020
Y0096_WEBOKMM21