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® 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 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 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.20201 1-80, 80 (TDD).Below is a summary of those issues that can be appealed or grieved through our member appeal and grievance process. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at, or by mail or phone at: U.S. If you need help filing a grievance, our Civil Rights staff is available to help you.You can also file a civil rights complaint with the U.S. ![]() Canton, OH 44710, 33, You can file a grievance in person or by mail, fax, or email. AultCare/Aultra provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages.If you need these services, or if you believe that AultCare/Aultra has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: AultCare/Aultra Civil Rights Coordinator, 2600 6th St. AultCare/Aultra provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). AultCare/Aultra does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ![]() AultCare/Aultra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sexual orientation, gender identity, or sex.
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