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Member Appeals/Complaints - PPO Group Health Plans
Complaint and appeal procedures for PPO group health plan members
ENDORSEMENT RESPECTING COMPLAINT/APPEAL PROCEDURE
IT IS AGREED that the Group Contract to which this Endorsement is issued for attachment is amended so that the Claim/Grievance Procedures or Complaint/Appeal Procedures currently reflected in the Contract, or in any endorsement attached thereto, are hereby deleted and restated as follows:
SECTION CG — COMPLAINT/APPEAL PROCEDURE
Blue Cross and Blue Shield of Oklahoma has established the following process to review Subscriber dissatisfactions, complaints and/or appeals. If the Subscriber has designated an authorized representative, that person(s) may act on his/her behalf in the appeal process.*
If the Subscriber has 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. If a resolution cannot be reached in an informal exchange, the Subscriber may request an administrative review of the problem through the Plan’s appeal process described below. The Subscriber may request to review information used to make any adverse determination. Copies will be provided free of charge.
A. APPEAL PROCESS (LEVEL I)
If the Subscriber is not satisfied with the initial attempt to resolve the problem, or if the Subscriber wishes to request a review of a Benefit determination or Precertification decision, the Subscriber must request an appeal within 180 days from the date he/she received notice of the adverse Benefit determination or Precertification notice. A Provider can also appeal the adverse Benefit determination or Precertification decision. The Provider's appeal will be considered an appeal on behalf of the Subscriber.
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 Subscriber must submit the 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 the Subscriber 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 Subscriber and/or the Provider should include any documentation, including medical records, that the Subscriber wants to become a part of the review file. The Plan may request further information if necessary.
a) In the case of an appeal involving a non-urgent Precertification request, the Plan will provide a written response to the Subscriber no later than 30 days following the date the appeal is received.
b) In the case of an appeal involving a claim other than a Precertification request, the Plan will provide a written response to the Subscriber no later than 60 days following the date the appeal is received.
2. How to File an Appeal of a Precertification Request Involving Urgent Care
If the Subscriber and/or the Provider wish to appeal a Precertification Request Involving Urgent Care, he/she may appeal by calling the Precertification number shown on the Identification Card.
a) The Plan will respond to the Subscriber no later than 72 hours after the appeal request is received.
b) 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.
B. VOLUNTARY RE-REVIEW PROCESS (LEVEL II)
If the Subscriber is not satisfied with the decision concerning the appeal, the Subscriber may elect to submit the adverse Benefit determination to the Plan for re-review. The Plan will provide the Subscriber with information about the Plan’s voluntary re-review process.
To request a re-review of the Benefit determination, the Subscriber should submit the 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 the Subscriber 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 Subscriber should include any documentation, including medical records, that the Subscriber wants to become a part of the review file. The Plan may request further information if necessary.
A Precertification Request Involving Urgent Care may be re-reviewed by calling the Precertification number shown on the Identification Card.
C. EXTERNAL REVIEW (LEVEL III)
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, the Plan will notify the Subscriber, in writing, of the procedure to obtain an external review as set forth in the Oklahoma Managed Care Review Act.
The Subscriber is not obligated by the Group Health Plan to pursue the Plan's voluntary re-review process or an external review in any specific order. The Subscriber is not required to exhaust the voluntary re-review process before bringing a civil action. If the review processes do not provide a satisfactory resolution to the claim for Benefits, legal remedies are available, including pursuing the claim in court.
This endorsement is effective October 15, 2006, or the effective date of the Contract to which it is issued for attachment, whichever is later.
Except as amended, the Contract remains unchanged.
* The Plan has established procedures for a Subscriber to designate an individual to act on his/her behalf with respect to a Benefit claim or an appeal of an adverse Benefit determination. A Provider or other health care professional with knowledge of the Subscriber's medical condition is permitted to act as the Subscriber's authorized representative or bring an appeal on behalf of the Subscriber.
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