SeniorBlue PPO Member Appeal and Grievance Form_C-354

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SeniorBlue PPO Member Appeal and Grievance Form_C-354 Powered By Docstoc
					                                                                    Member Appeal and
                                                                       Grievance Form
To appeal a claim or denial of service in whole or in part your appeal or grievance must be
filed within 60 days of the initial determination or date of the event. Please attach copies of all
documentation you may have in relation to this request and include any additional information,
which may support your complaint. This form along with your documentation may be mailed or
faxed to: Member Appeal and Grievance Department
          SeniorBlue PPO
          P.O. Box 779518
          Harrisburg, PA 17177-9518
          Fax: 717-541-6915

Member Information
Member Name:                                                      Date of Birth:


City:                                            State:                            Zip:

Daytime Telephone:                               Evening Telephone:

Identification Number:                           Medicare Number:

Group Name:                                      Group Number:

Claims/Service You are Grieving or Appealing

City:                                            State:                            Zip:


City:                                            State:                            Zip:

Other Provider:

City:                                            State:                            Zip:

Date of Service:                     Claim Number:                  Authorization Number:

H3962_H3923 08_015 08/18/2008                                                               C-354 (2/2010)
Reason for Grievance or Appeal

If you wish to be represented by another person at any point in this process, you will need to
sign, date, and return a Appointment of Representative (AOR) Form to serve as a statement
naming the individual to advocate on your behalf, and provide the following information:

Name:                                              Daytime Telephone Number:

Relationship to Member:


City:                                              State:                            Zip:

Member Signature:                                                                    Date:

Important Information About Your Complaint Rights
For more information about your Appeal and Grievance Rights, please reference your Evidence of

If you have any question or require further assistance regarding this matter, please call our
Customer Service Department at 1-866-987-4213 (TTY 1-800-779-6961 for the hearing
impaired), Monday through Friday, between 8 a.m. and 8 p.m.

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries,
Capital Advantage Insurance Company® and Keystone Health Plan® Central. Independent licensees
of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
Appeals involving                     Grievances involving                 Issues Involving
Medicare Advantage                    Medicare Advantage                   Prescription Drug
Plan Coverage                         Plan Coverage                        Coverage
Fast Track Appeal:                    First Level Grievance:               Appeal: (7 day review) a
(48 hour review) applies to           (30 day review) a written or         written request for any dispute
coverage termination of Skilled       oral dispute no later than sixty     concerning payment, failure to
Nursing, Home Health, and             (60) calendar days after the         arrange or continue to arrange
CORF services you may appeal          event.                               for, what a Member believes
by requesting an expedited                                                 are covered services.
review of the case by the QIO         Second Level Grievance:
in the State (i.e. Quality Insights   (30 day review) a written            Expedited Appeal:
of Pennsylvania) where the            dispute other than one               (72 hour review) a written/
services are being provided.          involving an organizational          oral request for any dispute
                                      determination that SeniorBlue        concerning payment, failure to
Appeal: (30 day pre-service           is unable to resolve in the          arrange or continue to arrange
60 day post-service review)           Member’s favor through the           for, what a Member believes is
a written request for any             first level grievance process.       covered services.
dispute concerning payment,           This grievance must be filed
failure to arrange or continue        within 60 days of the resolution     First Level Grievance:
to arrange for, what a Member         date of the first level grievance.   (30 day review) a written or
believes are covered services.                                             oral dispute regarding issues
                                      Expedited Grievance:                 such as: quality of care or
Expedited Appeal:                     (24 hour review) an oral or          services received, pharmacy
(72 hour review) a written or         written dispute other than one       waiting times, pharmacy delay,
verbal request for any dispute        involving an organizational          or other similar concerns.
concerning payment, failure           determination, that a Member
to arrange or continue to             deems an immediate resolution        Second Level Grievance:
arrange for, what a Member            is required. These grievances        (30 day review) a written
believes are covered services.        are to be handled as                 dispute other than one
For expedited appeals, either         expeditiously as the Member’s        involving an organizational
the Member or the Member’s            health requires.                     determination that the Plan
doctor, believes applying the                                              is unable to resolve in the
standard time frame could                                                  Member’s favor through the
seriously jeopardize the                                                   first level grievance process.
Member’s life, health, or ability
to regain maximum function.                                                Expedited Grievance:
                                                                           (24 hour review) a written
                                                                           dispute other than one
                                                                           involving an organizational
                                                                           determination, that a Member
                                                                           deems an immediate resolution
                                                                           is required.

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