![]() ![]() The BCBSAZ standard member appeal/grievance dispute processes and time frames do not apply to: U-Haul (group # 026229 member ID prefix UHL)įor help in determining which appeal packet to use for a particular member, call the Medical Appeals and Grievance Department at 60 or 1-86.Įxpedited appeals require the treating provider to certify orally or in writing that the time periods required to process standard appeals could seriously jeopardize the member’s life, health, or ability to regain maximum function, cause a significant negative change in the member’s medical condition at issue, or subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.Įxceptions to the Standard Appeal/Grievance Dispute Processes and Time Frames.Teamsters (group #s 3184 member ID prefix TYW).State of Arizona (group # 30855 member ID prefixes SYD and S3Z).Standard Appeal/Grievance Packet 2 – for all self-funded employer groups, except those that have their own customized appeal packets, including:.Standard Appeal/Grievance Packet 1 – for most BCBSAZ members.Providers will use one of two “standard” appeals packets available below. ![]() The specific dispute processes are explained in the appeal/grievance packet, which also includes all related forms. However, some large, self-funded employer groups have benefit plans that require additional regulatory procedures and may have customized timelines and other protocols that deviate from the process We have a defined appeal/grievance process for members and their treating providers. If the provider or member does not provide documentation, we will decide the appeal using only the information we already have. We do not solicit records to support an appeal/grievance. The provider and member are responsible for sending all relevant information to support a dispute and show why we should change our original decision. All other documentation that supports the appeal, such as medical records, operative reports, office notes.Pharmacy coverage guidelines are available at /pharmacy.Clinical criteria are available on the secure provider portal at “Practice Management > Medical Policies”.Documentation that disputed services meet the clinical criteria or pharmacy coverage guidelines.A written explanation of why the action may be incorrect, and the relief requested.A reference to the action or copy of the decision notice that is being appealed.To enable us to timely and accurately respond to an appeal/grievance, providers should include the following information: For BlueCard® (out-of-area) members, be sure to check the member’s benefit book for appeal information.ĭocumentation to include when supporting a BCBSAZ member appeal/grievance Note: Not all states allow providers to initiate an appeal/grievance on behalf of a member. In these cases, a provider who is appealing on a member’s behalf should use the Authorized Representative Designation Form to send us the patient’s authorization allowing the provider to receive appeal information on the patient’s behalf.Ī provider initiating an appeal on behalf of a member should send the patient a copy of all information shared with us in connection with the appeal or grievance. However, a few BCBSAZ plans for self-funded groups require specific member authorization before the provider can pursue an appeal for the member. A parent acting on the behalf of a minor.The treating provider acting on the member’s behalf.For most BCBSAZ plans, the following individuals are always authorized to appeal or grieve a decision and do not need any special authorization form: Laws and benefit plans vary regarding a provider’s right to initiate an appeal/grievance on behalf of a member. Rescinds the member’s coverage under the plan.Determines that the member is not eligible for coverage under the benefit plan.Finds that a service is not covered because it is experimental or investigational.Finds that a service is not medically necessary.Finds the member responsible for payment of cost share (copay, deductible, coinsurance, access fee, balance bill) for a plan benefit.Finds the member ineligible for a benefit under his or her plan.Fails to provide or pay for a benefit covered under the member’s plan.Denies, reduces, or terminates the member’s plan benefits.Denies a claim for services already received.Denies a request for preauthorization of a service not yet received.Below is a summary of those issues that can be appealed or grieved through our member appeal and grievance process. ![]()
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