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Administration of Your PlanHow to voice a complaintCareFirst BlueChoice wants to hear your concernsand/or complaints so they may be resolved. Wehave procedures to address medical and nonmedicalissues. If a situation should occur forwhich there is any question or difficulty, here’swhat to do:➤ If your comment or concern is regarding thequality of service received from a CareFirstBlueChoice representative or administrativeproblems (e.g., enrollment, claims, bills, etc.),you should contact Member Services. To writeto us directly with a quality of care or serviceconcern, you can:n Send an email to:quality.care.complaints@carefirst.comn Fax a written complaint to (301) 470-5866n Write to:CareFirst BlueCross BlueShieldQuality of Care DepartmentP.O. Box 17636Baltimore, MD 21297If you send your comments to us in writing,please include your ID number and provide uswith as much detail as possible. Please include yourdaytime phone number so we may contact youdirectly if we need additional information.➤ For concerns or complaints about the qualityof care or quality of service received from aspecific provider, contact Member Service at thephone number listed or your member ID card. Arepresentative will record your concern and mayrequest a written summary of the issues. You canalso submit a complaint by sending an e-mailto quality.care.complaints@carefirst.com.A written complaint can be faxed to (301) 470-5866. Please include your ID number and provideus with as much detail as possible regardingany events. Please include your daytime phonenumber so we may contact you directly if we needadditional information. The substance of thecomplaint will be investigated as appropriate andthe action taken will be thoroughly documented.These procedures are also outlined in your Evidenceof Coverage/Agreement.If you wish, you may also contactthe appropriate jurisdiction’sregulatory department regardingyour concern:Virginia:Office of the Managed CareOmbudsmanBureau of InsurancePO Box 1157Richmond,VA 23218(877) 310-6560 or(804) 371-9032ombudsman@scc.virginia.govOffice of Licensure andCertification Complaint IntakeVirginia Department of Health9960 Mayland Drive, Suite 401Richmond, VA 23233-1463Phone: (800) 955-1819(804) 367-2106District of Columbia:Office of Health CareOmbudsman and Bill of RightsOne Judiciary Square441 4th Street, NW, 9th FloorWashington, DC 20001Phone: (877) 685-6391Fax: (202) 535-1216Maryland:Maryland InsuranceAdministration Inquiry andInvestigation, Life and Health200 St. Paul Place, Suite 2700Baltimore, MD 21202-2272(410) 468-2244 or (800) 492-6116Fax: (410) 468-2270www.mdinsurance.state.md.usOffice of Health Care QualitySpring Grove CenterBland-Bryant Building55 Wade AvenueCatonsville, MD 21228(877) 402-8218Fax: (410) 402-8215www.dhmh.state.md.us/ohcqFor assistance in resolving abilling or payment disputewith the health plan ora health care provider,contact the Health Educationand Advocacy Unit ofthe Consumer ProtectionDivision of the Office of theAttorney General at:Health Education andAdvocacy UnitConsumer ProtectionDivisionOffice of the AttorneyGeneral200 St. Paul PlaceBaltimore, MD 21202(410) 528-1840 or(887) 261-8807Fax: (410) 576-6571www.oag.state.md.us26 HealthyBlue Member Handbook
CareFirst BlueChoice’s appeal procedure is designedto enable you to have your concerns regarding a denialor reduction of benefits or a denial of authorization forservices heard and resolved. By following the stepsoutlined below, you can ensure your appeal is quickly andresponsively addressed.Please note that state mandates may alter the stepsbelow. Refer to your Evidence of Coverage/Agreement formore specific information regarding the appeals process.The procedure for filing an appeal is also located on ourwebsite at www.carefirst.com. In the Members & Visitorssection, click on “Frequently Asked Questions” in theSolution Center. If you would like a paper copy of theappeals process, you may also contact CareFirst BlueChoiceMember Services at the phone number located on yourmember ID card.Step 1:Inquiry and discussion of theproblemOften, Member concerns can be most effectivelyhandled and resolved through informal discussionsand information gathering. If your question orconcern is regarding our handling of a claim orother administrative action, the member or themember’s authorized representative should discussthe matter with the CareFirst BlueChoice MemberServices Department. The CareFirst BlueChoiceMember Services Department Customer ServiceRepresentative will contact the appropriateindividuals and gather information needed toanswer the question. In many instances, the mattercan be quickly resolved.Step 2:Appeal processIf your concern is not resolved through an informaldiscussion with a CareFirst BlueChoice CustomerService Representative, you or your authorizedrepresentative may make a formal request for anappeal.This appeal request should be in writing,addressed to our Member Services Department andstate the reason(s) for the request. In the event themember or the member’s authorized representativecannot put the request in writing, a CustomerService representative can assist you. The requestfor an appeal must be made within six (6) monthsor at least 180 days from the date of the notificationof denial of benefits. A decision by the Plan shallbe made within 30 calendar days for a pre-serviceappeal, or 45 working days for a post service appeal.The appeal of a medical necessity decision shallbe reviewed, as appropriate, by a physician of thesame or similar specialty as the treatment underreview. The physician review of the appeal will beperformed by a physician who was not part of theoriginal denial.An expedited appeal process has been establishedin the event that a delay in a decision would beseriously detrimental to your health or the healthof a covered family member. Expedited appealsinvolve care that has not yet occurred or is currentlyoccurring (pre-service or concurrent care). In anexpedited appeal, a decision shall be made within 24hours of receipt. The physician review of the appealwill be performed by a physician who was not part ofthe original denial decision.The expedited appeal review will be, asappropriate, reviewed by a physician in the same orsimilar specialty as the treatment under review.All appeal decisions will be communicatedin writing to the member, and include a detailedexplanation as to the reason for the decision, andany supporting documentation to show how thedecision was made. If the decision remains a denialof the benefits, a detailed explanation that referencesthe rule, policy or guideline used in making theappeal decision will be included. Also included inthis written appeal decision will be an explanationof the appropriate next steps a member or theauthorized member representative may take if theyare not satisfied with the appeal decision.Members have a right to an independent externalreview of any final appeal determination.If you wish, you may contact the insuranceregulatory department in your area to file acomplaint or an appeal regarding a denial orreduction of benefits. Refer to your Evidence ofCoverage/Agreement for more specific informationregarding initiating an external review of a finalappeal determination or a complaint.HealthyBlue Member Handbook27
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Page 4 and 5: Important InformationEmergency Assi
Page 6 and 7: Your HealthyBlue 2.0 Member ID Card
Page 8 and 9: HealthyBlue — The BasicsAs a Heal
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Page 14 and 15: Frequently Asked QuestionsWhy is my
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Page 23 and 24: Additional BenefitsHow to Access In
Page 25 and 26: Health + WellnessUtilization Manage
Page 27: Administration of Your PlanPersonal
Page 31 and 32: All health plans and providers must
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HealthyBlue 2.0/HealthyBlue Advantage Member ... - CareFirst

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