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Member Appeals/Complaints - Individual Health Plan
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 individual health plan members
Blue Cross and Blue Shield of Oklahoma has established the following process to review Subscriber dissatisfactions, complaints, and/or appeals. If you have designated an authorized representative, that person may act on your behalf in the appeal process.
If you have a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with a Blue Cross and Blue Shield of Oklahoma Customer Service Representative. In most cases, a Customer Service Representative will be able to provide you with a satisfactory solution to your problem. However, if a resolution cannot be reached in an informal exchange, you may request an administrative review of the problem through our appeal process described below.
You may request to review information used to make any adverse determination. Copies will be provided free of charge.
Level I - Appeal
Level II - Reconsideration Process
Level III - Additional Rights
1. Level I – Appeal
A. How and When to File an Appeal
If you are not satisfied with the initial attempt to resolve your problem, or if you wish to request a review of a Benefit determination or Precertification decision, you must request an appeal within 180 days from the date you received notice of the adverse Benefit determination or 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, you must submit your request in writing to the following address:
Appeal Coordinator — Customer Service Department
Blue Cross and Blue Shield of Oklahoma
P. O. Box 3283
Tulsa, Oklahoma 74102-3283
The written request should include the name of the Subscriber, the Subscriber identification number, the nature of the complaint, the facts upon which the complaint is based, and the resolution you are 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). You should include any documentation, including medical records, that you want to become a part of the review file. The Plan may request further information if necessary.
2) How to File an Appeal of a Precertification Request Involving Urgent Care
If you wish to appeal a Precertification Request Involving Urgent Care, you may appeal by calling the Precertification number shown on your Identification Card.
B. The Appeal Process
1) Appeal Involving a Non-Urgent Request or Claim
The Plan’s Benefits Administration staff will review your appeal, unless it involves medical judgment. Appeals that require medical judgment are reviewed by a Medical Director of Blue Cross and Blue Shield of Oklahoma. 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, the Plan 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 Precertification request, the Plan will provide a written response to you no later than 30 days following the date we receive your appeal.
In the case of an appeal involving a claim other than a Precertification request, the Plan will provide a written response to you no later than 60 days following the date we receive your appeal.
2) Appeal of a Precertification Request Involving Urgent Care
A “Precertification Request Involving Urgent Care” (see page 7) will be reviewed by a Medical Director of Blue Cross and Blue Shield of Oklahoma. 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, the Plan may consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.
The Plan will respond to you no later than 72 hours after receipt of your appeal request.
NOTE: The Plan’s response to a Precertification 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 – Reconsideration Process
After exhaustion of the Level I appeal process outlined above, if you are not satisfied with the resolution, you have the right to submit your Benefit dispute to the Plan for a Level II reconsideration. You must exhaust the Level I and Level II appeal processes before pursuing other legal remedies.
To request a Level II reconsideration of your Benefit determination, you must submit your request in writing to the following address:
Appeal Coordinator – Customer Service Department
Blue Cross and Blue Shield of Oklahoma
P. O. Box 3283
Tulsa, Oklahoma 74102-3283
The written request should include the name of the Subscriber, the fact that it is a Level II appeal, the Subscriber identification number, the nature of the complaint, the facts upon which the complaint is based, and the resolution you are 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). You should include any documentation, including medical records, that you want to become a part of the review file. The Plan may request further information if necessary.
A. Member Participation and Protection Committee Review
Your Level II review will be directed to the Plan’s Member Participation and Protection Committee. The purpose of this committee is to protect your rights and to provide a mechanism to review and resolve issues which are not resolved to your satisfaction through the Level I appeal process. This committee is comprised of representatives of functional areas of Blue Cross and Blue Shield of Oklahoma, medical staff, and insured Members who are not employed by the Plan. The committee’s determination will be made within 60 days following receipt of your request, unless, in the Plan’s opinion, additional time is needed to complete the review. In such case, the Plan will issue written notice, on or before the 60th day, advising the Subscriber of an extension, not to exceed 60 days. Written notice of the committee’s determination will be issued to the Subscriber.
B. Medical Review
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.
3. Level III – Additional Rights
For services that are denied as not Medically Necessary, medically appropriate, or medically effective, Oklahoma law gives you the right to an external review by an independent review organization. You must first exhaust the Level I and Level II appeal processes set forth above. If requested, the Plan will notify you, in writing, of the procedure to obtain an external review as set forth in the Oklahoma Managed Care External Review Act.
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