Appeals & Grievances
General Appeals & Grievances
An organization determination (coverage decision) is the initial decision we make about your benefits and coverage. It can also be about the amount we will pay for your medical services or drugs. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal.
If we make a coverage decision and you are not satisfied with part or all of our decision, you or your representative can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal." When you make an appeal, we review the coverage decision we have made to check to see if we were following all the benefits properly. When we have completed the review, we will give you our decision in writing. If we say no to all or part of your Level 1 Appeal, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. These additional levels are explained in your Evidence of Coverage.
A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Evidence of Coverage. If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 888-850-8526 (TTY/TDD: 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Premera Blue Cross Medicare Advantage Plans Grievance Procedure. To use the formal grievance procedure, you may submit your written grievance to the Premera Blue Cross Medicare Advantage Appeals and Grievance Department. If you file a written grievance, or your complaint is related to quality of care and we have your consent to investigate, we will respond in writing to you.
To file a grievance, you or your representative may:
- Call: 888-850-8526 (TTY/TDD: 711)
- Online: Click here
- Fax: 800-889-1076
Premera Blue Cross Medicare Advantage Plans
Attn: Appeals and Grievances Department
PO Box 262527
Plano, TX 75026
For quality-of-care problems, you may also complain to the Quality Improvement Organization (QIO).
You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. Please refer to Chapter 2, Section 4, of your Evidence of Coverage for additional information about the Quality Improvement Organization in your state.
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.
If you would like someone else to act on your behalf, please fill out this form (.pdf), sign it, and return it to us.
Premera Medicare Advantage Plans
PO Box 262527
Plano, TX 75026
Part D Appeals & Grievances
There are times when you may have a problem or concern regarding your Part D (prescription drug coverage). The following will help you with that process.
Coverage determinations are the first decisions made by the plan that determine whether to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.
"Standard" Coverage Determination: the decision will typically be made within a 72-hour timeframe.
"Fast" or "expedited" Coverage Determination: ONLY available if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. “Fast" decisions only apply for Part D drugs that you have not yet received. A fast coverage determination is made typically within 24 hours.
You, your prescriber, or member representative may ask for a coverage decision electronically by completing our secure, online Medicare Coverage Determination Form.
You can also make this request by completing the Prescription Drug Coverage Determination Form (.pdf) and faxing or mailing it to us.
An appeal is the process that deals with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.
A "standard" appeal decision means we have up to 7 calendar days from the time we receive your request to decide.
A "fast" appeal decision means an appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.
You, your doctor, or your representative can complete our secure, online Drug Coverage Redetermination Form.
You can also make this request by completing the Drug Coverage Redetermination Form (.pdf) and faxing or mailing it to us.
To check status or to request a "standard," "fast," or "expedited" coverage determination or appeal: You, your appointed representative, or your prescribing physician should contact us by telephone, fax, or mail at the numbers or address below:
A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits. Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint. If you request a "fast" grievance, a decision will be rendered within 24 hours.
To check status or to file a grievance: You or your appointed representative should contact us by telephone or mail to the address below:
Please refer to Chapter 9 of your plan's Evidence of Coverage (EOC) for more information regarding grievance, determination, and appeals processes. You may contact customer service with any questions or concerns, including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with Premera Blue Cross Medicare Advantage Plans.
If you'd like to find out the total number of grievances, appeals, and exception requests Premera members have filed with us, please call 888-850-8526 (TTY/TDD: 711). April 1 to September 30, Monday to Friday, 8 a.m. to 8 p.m. October 1 to March 31, 7 days a week, 8 a.m. to 8 p.m.
Learn about Medicare plans offered in your area.