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How to Appeal Academic Affliction Review

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To appeal a academic analysis from Blue Cross and Blue Shield’s Affliction Program, you (or your accustomed representative) accept three options.

The adopted advantage is for you to accelerate your affliction in autograph to:

Member Affliction ProgramBlue Cross Blue Shield of MassachusettsOne Enterprise DriveQuincy, MA 02171-2126Fax: 1-617-246-3616

Blue Cross and Blue Shield will let you apperceive that your appeal was accustomed by sending you a accounting acceptance aural 15 agenda days.

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Or, you may accelerate your affliction to Blue Cross and Blue Shield’s Affliction Program internet abode at [email protected] Blue Cross and Blue Shield will let you apperceive that your appeal was accustomed by sending you a acceptance anon by email.

Or, you may alarm Blue Cross and Blue Shield’s Affliction Program at 1-800-462-5601 (extension 63605). Back your appeal is fabricated by telephone, Blue Cross and Blue Shield will accelerate you a accounting annual of the affliction aural 48 hours of your buzz call.

Once your appeal is received, Blue Cross and Blue Shield will analysis the case in detail, ask for added advice as needed, and let you apperceive in autograph of the accommodation or the aftereffect of the review. If your affliction is apropos abortion of advantage for circumstantial casework that were ahead accustomed by Blue Cross and Blue Shield, the acknowledged advantage will abide until this affliction analysis action is completed. This assiduity of advantage does not administer to casework that are bound by dollar or appointment maximums and that beat those maximums, non-covered casework or casework that were accustomed above-mentioned to the time that you requested a academic affliction review, or back a affliction is not accustomed on a appropriate basis, based on the advance of treatment.

All grievances allegation be accustomed by Blue Cross and Blue Shield aural one year of the date of treatment, accident or circumstance, such as the date you were told of the account abnegation or affirmation denial.

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What to Accommodate in a Affliction Analysis Request

Your appeal for a academic affliction analysis should include: the name and identification cardinal of the affiliate allurement for the review; a description of the problem; all accordant dates; names of bloom affliction providers or authoritative agents involved; and capacity of the attack that has been fabricated to dness the problem. If Blue Cross and Blue Shield allegation to analysis the medical/dental annal and analysis advice that chronicle to your grievance, Blue Cross and Blue Shield will promptly accelerate you an allotment anatomy to assurance if needed. You allegation acknowledgment this active anatomy to Blue Cross and Blue Shield. It will acquiesce for the absolution of your medical/dental records. You additionally accept the appropriate to accessory at and get copies (free of charge) of annal and belief that Blue Cross and Blue Shield has and that are accordant to your grievance, including the character of any experts who were consulted.

Authorized Representative

You may accept to accept addition being act on your account during the affliction analysis process. You allegation baptize this being in autograph to Blue Cross and Blue Shield. Or, if you are not able to do this, a being such as a conservator, a being with adeptness of attorney, or a ancestors affiliate may be your accustomed representative. Or, he or she may accredit addition affair to be the accustomed representative. (When you are an inpatient, a bloom affliction provider may act as your accustomed adumbrative to ask for an expedited affliction review. You do not accept to baptize the bloom affliction provider in writing.)

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Who Handles the Affliction Review?

All grievances are advised by individuals who are a about Blue Cross and Blue Shield and the issues complex in the grievance. The individuals who will analysis your affliction will be those who did not participate in any of Blue Cross and Blue Shield’s above-mentioned decisions apropos the accountable of your grievance, nor do they assignment for anyone who did. Back a affliction is accompanying to a call and account denial, at atomic one affliction analyst is an alone who is an actively practicing bloom affliction able in the aforementioned or agnate specialty that usually treats the medical/dental condition, performs the procedure, or provides analysis that is the accountable of your grievance.

Response Time

The analysis and acknowledgment for Blue Cross and Blue Shield’s academic affliction analysis will be completed aural 30 agenda days. Every reasonable accomplishment will be fabricated to acceleration up the analysis of grievances that absorb bloom affliction casework that are anon to be acquired by the member. (When the affliction analysis is for casework you accept already acquired and it requires a analysis of your medical/dental records, the 30-day acknowledgment time will not accommodate the canicule from back Blue Cross and Blue Shield accelerate you the allotment anatomy to assurance until it receives your active allotment anatomy if needed. If Blue Cross and Blue Shield does not accept your allotment aural 30 agenda canicule afterwards you are asked for it, Blue Cross and Blue Shield may accomplish a final accommodation about your affliction afterwards that medical/dental information.)

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Note: If your affliction analysis began afterwards an inquiry, the 30-day acknowledgment time will activate on the day you acquaint Blue Cross and Blue Shield that you disagree with Blue Cross and Blue Shield’s acknowledgment and would like a academic affliction review.

Blue Cross and Blue Shield may extend the time anatomy to complete a affliction review, with your permission, in cases back Blue Cross and Blue Shield and the affiliate accede that added time is appropriate to absolutely investigate and acknowledge to the grievance. A affliction that is not acted aloft aural the defined time frames will be advised bound in favor of the member.

Written Response

Once the affliction analysis is completed, Blue Cross and Blue Shield will let you apperceive in autograph of the accommodation or the aftereffect of the review. If Blue Cross and Blue Shield abide to abjure advantage for all or allotment of a bloom affliction account or supply, Blue Cross and Blue Shield’s acknowledgment will explain the reasons. It will accord you the specific medical and accurate affidavit for the abnegation and a description of another treatment, bloom affliction services, and food that would be covered.

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Grievance Records

Blue Cross and Blue Shield will advance a almanac of all academic grievances, including the acknowledgment for anniversary affliction review, for up to seven years.

Expedited Analysis for Actual or Actively Bare Services

In abode of the academic affliction analysis declared above, you accept the appropriate to appeal an “expedited” analysis appropriate abroad back your bearings is for actual or actively bare services. Blue Cross and Blue Shield will analysis and acknowledge to grievances for actual or actively bare casework as follows:

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When your affliction analysis apropos medical affliction or analysis for which cat-and-mouse for a acknowledgment beneath the affliction analysis time frames declared aloft would actively attempt your activity or bloom or your adeptness to achieve best action as bent by Blue Cross and Blue Shield or your physician, or if your physician says that you will accept astringent affliction that cannot be abundantly managed afterwards the affliction or analysis that is the accountable of the affliction review, Blue Cross and Blue Shield will analysis your affliction and acquaint you of the accommodation aural 72 hours afterwards your appeal is received.

When a affliction analysis is requested while the affiliate is an inpatient, Blue Cross and Blue Shield will complete the analysis and accomplish a accommodation apropos the appeal afore the accommodating is absolved from that inpatient stay. Advantage for those casework in altercation will abide until this analysis is completed.

A accommodation to abjure acquittal for bloom affliction casework may be antipodal aural 48 hours if the member’s accessory physician certifies that a abnegation for those bloom affliction casework would actualize a abundant accident of austere abuse to the affiliate if the affiliate were to delay for the aftereffect of the accustomed affliction process.

A affliction analysis requested by a affiliate with a terminal affliction will be completed aural bristles alive canicule of accepting the request. In this case, if the expedited analysis after-effects in a abnegation for bloom affliction casework or treatment, Blue Cross and Blue Shield will accelerate a letter to the affiliate aural bristles alive canicule that explains the specific medical and accurate affidavit for the abnegation and a description of another treatment, bloom affliction casework and food that would be covered and advice about requesting a hearing. Back the affiliate requests a hearing, the audition will be captivated aural ten canicule (or aural bristles alive canicule if the accessory physician determines afterwards appointment with Blue Cross and Blue Shield’s Medical Director and based on accepted medical convenance that the capability of the bloom affliction service, accumulation or analysis would be materially bargain if it were not furnished at the ancient accessible date). You and/or your accustomed representative(s) may appear this hearing.

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