Appeals and Grievances

At Blue Cross and Blue Shield of Illinois (BCSBIL), we take great pride in ensuring that you receive the care you need. But if you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal.

Grievance (Complaint):

A grievance is a complaint about any matter besides a service that has been denied, reduced or ended.

BCBSIL takes member complaints very seriously. We want to know what is wrong so we can make our services better. If you have a complaint about a provider or about the quality of care or services you have received, you should let us know right away. BCBSIL has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to meet your concern. Filing a complaint will not change your health care services or your benefits coverage.

You may want to file a grievance if:

• Your provider or a BCBSIL employee did not respect your rights
• You had trouble getting an appointment with your provider in an reasonable amount of time
• You were unhappy with the care or treatment you received
• Your provider or a BCBSIL employee was rude to you
• Your provider or a BCBSIL employee did not respect your cultural needs or other special needs you may have

Appeals:

An appeal is a way for you to ask for someone to review our actions. You might want to file an appeal if BCBSIL:

• Does not approve a service your provider asks for
• Stops a service that was approved before
• Does not pay for a service your PCP or other provider asked for
• Does not give you the service in a timely manner
• Does not answer your appeal in a timely manner
• Does not approve a service for you because it was not in our network

If BCBSIL decides that a requested service cannot be approved, or if a service is reduced, stopped or ended, you will get a “Notice of Action” letter from us. You must file your appeal within 60 calendar days from the date on the Notice of Action letter. This letter will tell you the following:

• What action was taken and the reason for it
• Your right to file an appeal and how to do it
• Your right to ask for a State Fair Hearing and how to do it
• Your right in some circumstances to ask for an expedited appeal and how to do it
• Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services

How to File an Appeal or Grievance:

There are two ways to file an appeal or grievance (complaint):

• Call Member Services at 1-877-860-2837. If you do not speak English, we can provide an interpreter at no cost to you. If you are hearing impaired, call the Illinois Relay at 711.
• Write to us at:

Blue Cross Community Health Plans
Attn: Grievance and Appeals Unit
P.O. Box 660717
Dallas, TX 75266-0717
Fax: 1-866-643-7069

If you would like to appeal a pharmacy service, you can:

• Call Member Services at 1-877-860-2837. If you do not speak English, we can provide an interpreter at no cost to you. If you are hearing impaired, call the Illinois Relay at 711.
• Write to us at:

Blue Cross Community Health Plans
Attn: Prime Therapeutics Appeals Department
2900 Ames Crossing Road
Eagan, MN 55121

• Send a fax to 1-855-212-8110.
• Have your provider submit an appeal online. They can visit MyPrime.com or CoverMyMeds.com to find out how.

After you file an appeal, we will call to tell you our decision and send you and your authorized representative a Decision Notice. If you disagree with the decision made on your appeal, you can ask for an External Review within 30 calendar days of the date on the Decision Notice. You may also ask for a State Fair Hearing Appeal within 120 calendar days of the date on the Decision Notice.

For more information regarding Appeals and Grievances, please check your Member Handbook.