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Member Appeals/Complaints - BlueLincs HMO

Member Complaint / Appeal Procedures -The Blue Cross and Blue Shield of Oklahoma Family of Companies has established the following processes to review member dissatisfactions, complaints and/or appeals:

Complaint and appeal procedures for BlueLincs HMO group health plan members

BlueLincs has established the following process to review Member dissatisfactions, complaints and/or appeals. If the Member has designated an authorized representative, that person may act on the Member’s behalf in the appeal process.

If the member has a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with a BlueLincs Member Services Representative. If a resolution cannot be reached in an informal exchange, the Subscriber may request an administrative review of the problem through BlueLincs’ appeal process described below.

The Member may request to review information used to make any adverse determination. Copies will be provided free of charge.

Level I - Appeal

Level II - Voluntary Reconsideration Process

Level III - Additional Rights

1. Level I – Appeal

A. How and When to File an Appeal

If the Member is not satisfied with the initial attempt to resolve the problem, or if the Member wishes to request a review of a benefit determination or Preauthorization/Precertification decision, the Member must request an appeal within 180 days from the date he/she received notice of the adverse benefit determination or Preauthorization/Precertification notice.

1) How to File an Appeal Involving a Non-Urgent Request or Claim

In the case of an appeal involving a non-urgent request or claim, the Member must submit the request in writing to the following address:

Member Appeal Coordinator — Member Services Department
BlueLincs HMO
P. O. Box 21128
Tulsa, Oklahoma 74121-1128

The written request should include the name of the Member, the BlueLincs identification number, the nature of the complaint, the facts upon which the complaint is based, and the resolution the Member is seeking. Necessary facts are: dates and places of services, names of Providers of services, place of hospitalization and types of services or procedures received (if applicable). The Member should include any documentation, including medical records, that the Member wants to become a part of the review file. BlueLincs may request further information if necessary.

Within seven working days following BlueLincs’ receipt of a Level I request, the Member will receive written notification outlining his/her rights and the time frames for determination.

2) How to File an Appeal of a Preauthorization/Precertification Request Involving Urgent Care

If the Member wishes to appeal a Request Involving Urgent Care, he/she may appeal by contacting Member Services at 1-800-580-6202.

B. The Appeal Process

1) Appeal Involving a Non-Urgent Request or Claim

BlueLincs’ Benefits Administration management will review the Member’s appeal, unless it involves medical judgment. Appeals that require medical judgment are reviewed by a BlueLincs Medical Director. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or appropriate, BlueLincs may consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.

In the case of an appeal involving a non-urgent Preauthorization/Precertification request, BlueLincs will provide a written response to the Member no later than 30 days following the date the appeal is received.

In the case of an appeal involving a claim other than a Preauthorization/Precertification request, BlueLincs will provide a written response to the Member no later than 60 days following the date the appeal is received.

2) Appeal of a Request Involving Urgent Care

A “Request Involving Urgent Care” will be forwarded to the BlueLincs Medical Director. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or
appropriate, BlueLincs may consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.

BlueLincs will respond to the Member no later than 72 hours after the appeal request is received.

BlueLincs’ response to a Request Involving Urgent Care, including an adverse determination, if applicable, may be issued orally. A written notice will also be provided within three days following the oral notification.

2. Level II – Voluntary Reconsideration Process

After exhaustion of the appeals process outlined above, the Member may elect to submit the benefit dispute to BlueLincs for reconsideration. BlueLincs will provide the Member with information necessary to make an informed judgment about BlueLincs’ voluntary review process.

BlueLincs will not charge the Member any fees or costs as a part of the voluntary review process. If the Member elects to pursue his/her voluntary review rights, any statute of limitations or other defense based on timeliness will be tolled during the time that any voluntary review is pending.

BlueLincs cannot claim that the Member failed to exhaust the administrative remedies available to him/her for failing to submit the benefit dispute to BlueLincs’ voluntary review process.

To request a Level II reconsideration of the benefit determination, the Member should submit the request in writing to the following address:

Member Appeal Coordinator — Member Services Department
BlueLincs HMO
P. O. Box 21128
Tulsa, Oklahoma 74121-1128

The written request should include the name of the Member, the BlueLincs identification number, the nature of the complaint, the facts upon which the complaint is based, and the resolution the Member is seeking. Necessary facts are: dates and places of services, names of Providers of services, place of hospitalization and types of services or procedures received (if applicable). The Member should include any documentation, including medical records, that the Member wants to become a part of the review file. BlueLincs may request further information if necessary.

Within seven working days following BlueLincs’ receipt of a Level II request, the Member will receive written notification outlining his/her rights and the time frames for determination.

A Request Involving Urgent Care may be appealed by contacting Member Services at 1-800-580-6202.

The voluntary review will be directed to the BlueLincs Grievance Committee. The purpose of this committee is to protect the Member’s rights and to provide a mechanism to review and resolve issues which are not resolved to the Member’s satisfaction through the Level I appeal process. This committee is comprised of representatives of functional areas of BlueLincs, internal medical staff, external Physicians, and insured Members who are not employed by BlueLincs. A review of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or appropriate, will be referred to a health care professional who has appropriate training and experience in the applicable field of medicine.

The committee’s determination will be made within 60 days following receipt of the request, unless in BlueLincs’ opinion, additional time is needed to complete the review. In such case, BlueLincs will issue written notice, on or before the 60th day, advising the Member of an extension, not to exceed 60 days. Written notice of the committee’s determination will be issued to the Member.

3. Level III – Additional Rights

For services that are denied as not Medically Necessary, medically appropriate, or medically effective, Oklahoma law provides the right to an external review by an independent review organization. If requested, BlueLincs will notify the member, in writing, of the procedure to obtain an external review as set forth in the Oklahoma Managed Care External Review Act.

The Member is not obligated by the Group Health Plan to pursue Levels II or III voluntary reviews in any specific order, nor to exhaust Levels II or III voluntary reviews, before bringing a civil action. If these review processes do not provide a satisfactory resolution to the claim for benefits, legal remedies are available, including pursuing the claim in court.