Member Rights

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  • All BlueCare Plus Members have comprehensive rights and privileges concerning their health care insurance. Here you will find information concerning Coverage Decisions, Appeals and Filing a Grievance.
Appeals

Appeals

If you disagree with the decision we made about your claim or request for service, you have the right to file an appeal.  BlueCare Plus will look at the coverage decision we made to see if we were following all of the rules.  When we have completed the review we will give you our decision.  This is considered the first level of appeal and is called a request for reconsideration.

If we say no to all or part of your appeal, it will be automatically sent to the Independent Review Entity (IRE), Maximus Federal Services for review.

You may file an appeal within 60 calendar days of the date on the denial letter.  You may file an appeal by writing it on paper or filling out an appeal form. The Appeal form is located on our website and can be mailed to us at:

BlueCare Plus Member Appeals
1 Cameron Hill Circle, Suite 0042
Chattanooga, TN 37402

If you would like someone else to file an appeal for you, fill out the Appointment of Representative Form .  Both you and your representative must sign, and date the form and it must be filed with your appeal.

The person you appoint as your representative may:

  • Get information about your claim
  • Give us information you want us to know about your appeal
  • Make any request, give or receive any notice about the appeal actions

If you have any questions about the appeal process, please call out member service department at 1-800-332-5762 for assistance.  Our team is ready to listen and help.

How to appoint a representative?

If you would like to assign a representative to act on your behalf, both you and your representative must sign, date and complete an Appointment of Representative Form. This signed form must be filed with your coverage decision. Unless you decide you no longer want to have a representative, the form will be good for one year after the date the form is signed.

If future coverage decisions are filed during this time, your representative must file a photocopy of the signed representative form for each coverage decision. If your physician agrees to act as your representative and files a coverage decision for you, your physician cannot charge you for filing the coverage decision. Mail or fax the completed Appointment of Representative form to:

BlueCare Plus Member Appeals
1 Cameron Hill Circle, Suite 0042
Chattanooga, TN 37402
Fax: 1-888-416-3026

How to submit a Part D appeal?

Below is a link to the CMS model Redetermination Request form developed specifically for use by all Part D prescribing physicians or enrollees. You, your physician or your appointed representative should complete the form and mail, fax or email.

Request for Medicare Prescription Drug Coverage Redetermination

Phone:
1-844-648-9628
TTY users should call 1-800-716-3231
24 hours a day, 7 days a week

Mail:
Express Scripts, Inc.
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Fax:
1-877-328-9799

Email:
MedicarePartDPARequests@express-scripts.com

 

Grievances

Grievances

A grievance is a type of complaint you make about your plan or one of the network providers or pharmacy, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.  If you have a complaint about a coverage or claim denial, you file an appeal.

A member must file a grievance either orally or in writing no later than 60 days after the event or incident precipitating the grievance.

Listed below are examples of problems that are typically handled through the BlueCare Plus grievance process:

  • Problems getting an appointment, or having to wait a long time for an appointment
  • Disrespectful or rude behavior by doctors, nurses or other plan clinic or hospital staff

The Medicare health plan must include in its grievance procedures:

  • The ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 days after the event; and 
  • The requirement to respond within 24 hours to an enrollee's expedited grievance whenever:
    • A Medicare health plan extends the time frame to make an organization determination or reconsideration; or  
    • A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration.

BlueCare Plus will notify all concerned parties upon completion of the investigation as expeditiously as the member’s case requires based on the member's health status, but not later than 30 days after the grievance is received.

To file a grievance please contact us or fax your grievance to 1-888-416-3026.

Grievance Form

How to appoint a representative?

If you would like to assign a representative to act on your behalf, both you and your representative must sign, date and complete an Appointment of Representative Form. This signed form must be filed with your coverage decision. Unless you decide you no longer want to have a representative, the form will be good for one year after the date the form is signed.

If future coverage decisions are filed during this time, your representative must file a photocopy of the signed representative form for each coverage decision. If your physician agrees to act as your representative and files a coverage decision for you, your physician cannot charge you for filing the coverage decision. Mail or fax the completed Appointment of Representative form to:

BlueCare Plus Member Appeals
1 Cameron Hill Circle, Suite 0042
Chattanooga, TN 37402
Fax: 1-888-416-3026

Coverage Decisions

Coverage Decisions

If you think your health could be seriously harmed by waiting the standard 14 days for a decision, you may request a fast decision. BlueCare Plus must give you its decision within 72 hours if it is determined, or your doctor tells BlueCare Plus, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function. Expedited requests may be requested by a member, member's representative, or any physician, regardless of whether the physician is affiliated with BlueCare Plus.

A coverage determination or organization determination is any decision made by BlueCare Plus regarding:

  • Receipt of, or payment for, a managed care item or service;
  • A limit on the quantity of items or services.

You may call, write or fax BlueCare Plus to make your request for us to provide coverage for the medical care you want

Call:
1-800-332-5762 (TTY: 711)
8:00 a.m. to 9:00 p.m. EST, 7 days a week
If asked to leave a message, your call will be returned the next business day.

Mail:
BlueCross BlueShield of Tennessee
BlueCare Plus Operations
1 Cameron Hill Circle Ste 0002
Chattanooga, TN 37402-0002

Fax:
1-888-725-6849

If it is determined BlueCare Plus will not cover the items or services you asked for, we will tell you in writing why items or services will not be covered and how to appeal this decision. You'll get a notice explaining BlueCare Plus fully or partially denied your request and instructions on how to appeal our decision.

How to submit a Part D coverage determination

Below is a link to the CMS model Coverage Determination Request form developed specifically for use by all Part D prescribing physicians or enrollees. You, your physician or your appointed representative should complete the form and mail, fax or email.

Request for Medicare Prescription Drug Coverage Determination

Call:
1-844-648-9628
TTY users should call 1-800-716-3231
24 hours a day, 7 days a week

Mail:
Express Scripts, Inc.
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Fax:
1-877-328-9799

Email:
MedicarePartDPARequests@express-scripts.com

How to appoint a representative?

If you would like to assign a representative to act on your behalf, both you and your representative must sign, date and complete an Appointment of Representative Form. This signed form must be filed with your coverage decision. Unless you decide you no longer want to have a representative, the form will be good for one year after the date the form is signed.

If future coverage decisions are filed during this time, your representative must file a photocopy of the signed representative form for each coverage decision. If your physician agrees to act as your representative and files a coverage decision for you, your physician cannot charge you for filing the coverage decision. Mail or fax the completed Appointment of Representative form to:

BlueCare Plus Member Appeals
1 Cameron Hill Circle, Suite 0042
Chattanooga, TN 37402

Disenrollment

Disenrollment

When can you end your membership in our plan?

BlueCare Plus members are not subject to an annual election period. Members can enroll, disenroll, or change at any time. You may stay enrolled in BlueCare Plus unless you lose your Medicaid eligibility.

When must we end your membership in the plan?

We must end your membership in the plan if any of the following happen:

  • If you do not stay continuously enrolled in Medicare Part A and Part B.
  • If you move out of the service area for more than six months.
  • If you no longer meet the specific special needs status
  • If you become incarcerated.
  • If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
  • If you let someone else use your membership card to get medical care.
  • If you enroll in the Program of All-inclusive Care for the Elderly (PACE).

More detailed information is available

The information above is a brief overview of the BlueCare Plus disenrollment process. Please see Chapter 10 of your Evidence of Coverage for more information. We will provide Evidence of Coverage for all plans.

 

Contact Member Services to obtain a total number of grievances, appeals and exceptions filed with this plan.

BlueCare Plus Member Customer Service: 800-332-5762
Provider Customer Service: 800-299-1407

The Medicare Beneficiary Ombudsman is a person who reviews complaints (also called “grievances”) and helps resolve them. To contact the Medicare Beneficiary Ombudsman: call 1-800-MEDICARE or for more information visit medicare.gov.

This page was updated on October 1, 2017