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: Address: City: State: Zip: Daytime Telephone: Evening Telephone: Identification Number: Medicare Number: Group Name: Group Number: Claims/Service You are Grieving or Appealing Hospital: City: State: Zip: Doctor: City: State: Zip: Other Provider: City: State: Zip: Service/Procedure 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: Address: 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 Coverage. 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.