Grievances, Appeals and Coverage Decisions (2024)

A grievance is a complaint you make about BCBSIL or one of our network providers or pharmacies. This includes a complaint about the quality of your care. 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 a 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
• Your provider or BCBSIL does not give you the service in a timely manner
• Your provider or BCBSIL does not answer your appeal in a timely manner

For information about grievances for drugs, please see Plan Details/Drug Coverage.

An appeal is a way for you to challenge our action if you think BCBSIL made a mistake. 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 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.

For information about appeals for drugs, please see Plan Details/Drug Coverage.

For drugs, please refer to Plan Details/Drug Coverage to file an Appeal or Grievance.

For other services, there are two ways to file an appeal or grievance (complaint):

• Contact Us. 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
  Appeals and Grievances
  P.O. Box 660717
  Dallas, TX 75266-0717
  Fax:866-643-7069
  Fast Appeal Fax: 800-338-2227
  

  You can also contact Medicare by using the online complaint form.
  

Blue Cross and Blue Shield of Illinois uses clinical guideline criteria to make sure you get the health care you need. As a member, you can access the guidelines we use to make these coverage decisions. Learn more about accessing these guidelines.

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. Another term for coverage decision is prior authorization.

If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medicaid, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

If you need help making a coverage decision, you can ask any of these people:

• Contact Us
• Call the Illinois Department of Healthcare and Family Services Health Benefits Hotline for free help Monday through Friday from 8:00 a.m. to 4:45 p.m. The Illinois Health Benefits Hotline helps people enrolled in Medicaid with problems. The phone number is 1-800-226-0768, TTY: 1-877-204-1012.
• Call the Senior HelpLine for free help Monday through Friday from 8:30 a.m. to 5:00 p.m. The Senior HelpLine will help anyone at any age enrolled in this plan. The Senior HelpLine is an independent organization. It is not connected with this plan. The phone number is 1-800-252-8966, TTY: 1-888-206-1327.
• Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf.

To request a coverage decision:

• Contact Us. 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
  Appeals and Grievances
  P.O. Box 27838
  Albuquerque, NM 87215-9708
  Fax:312-233-4060

When you file an appeal or ask for a coverage decision, you may choose someone to act on your behalf. You may choose someone such as a relative, friend, lawyer or doctor. This person can ask for a coverage decision or make an appeal or grievance for you.

If you have chosen someone else to represent you, fill out an Appointment of Representative form. The form gives the person permission to act for you. You must give us a copy of the signed form.

If the appeal comes from someone besides you, we usually must get the completed Appointment of Representative form before we can review the appeal.

Note that under the Medicare program, your doctor or other provider can file an appeal without the Appointment of Representative form.

To learn more about asking for a representative, please Contact Us.

For more, please see the Forms and Documents page.