Personal Comp Member Handbook - CareFirst BlueCross BlueShield

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CareFirst’s appeals procedure is designed to enable youto have your concerns regarding a denial of benefitsor authorization for services heard and resolved. Byfollowing the steps outlined below, you can ensure thatyour appeal is quickly and responsively addressed. Pleasenote that state mandates may alter the steps below.Refer to your Certificate of Coverage for more specificinformation regarding your appeal process.An expedited appeals process has been established in theevent that a delay in a decision would be detrimental toyour health or the health of a covered family member.In an expedited appeal, a decision by CareFirst shallbe made within 24 hours from the time we receive theappeal. Review will be done by a physician in the same orsimilar specialty as the treatment under review, not partof the original denial decision, as appropriate. Expeditedappeals involve care that has not yet occurred or iscurrently occurring (pre-service or concurrent care).Your concerns can often be handled and resolvedthrough informal discussions and informationgathering. If your question relates to our handlingof a claim or other administrative action, call anddiscuss the matter with a CareFirst Member Servicesrepresentative. In many instances, the matter can bequickly resolved.If your concern is not resolved through a discussionwith a CareFirst representative, you or someoneauthorized on your behalf may make a formal requestfor appeal. CareFirst must receive the request within180 days of the date of receipt of notification of denialof benefits or services. If the request for appeal is relatedto a medical or clinical issue, a physician in the sameor similar specialty as the treatment under review,who was not part of the original denial decision, willreview the request. This request should be in writingand addressed to the Member Services Department.A Member Services representative will be available toassist you in submitting your appeal in the event youare unable to put the request in writing.All appeal decisions will be rendered in writing to themember. If the decision remains as a denial of theoriginal request, a detailed explanation that referencesthe rule, policy or guideline used to make the decisionwill be included. Also provided will be an explanationof the appropriate next steps a member may take ifhe/she is not satisfied with the appeal process. Membershave a right to an independent external review of anyfinal appeal or grievance determination.The procedure for filing an appeal is also located onour web site at www.carefirst.com. In the Members &Visitors section, click on “Frequently Asked Questions”in the Solution Center. If you would like a paper copy ofthe appeals process, you may also contact the MemberServices telephone number located on your memberID card. If you wish, you may contact the insuranceregulatory department in your area to file a complaintor an appeal regarding a denial or reduction of benefits.Maryland Insurance AdministrationInquiry and Investigation, Life and Health525 St. Paul PlaceBaltimore, MD 21202-2272(410) 468-2000 or (800) 492-6116Fax: (410) 468-2270www.mdinsurance.state.md.usHealth Education and Advocacy UnitConsumer Protection DivisionOffice of the Attorney General200 St. Paul PlaceBaltimore, MD 21202(410) 528-1840 or (887) 261-8807Fax: (410) 576-6571www.oag.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/ohcqAppeals Process 25
Page 1 and 2: Your Member Handbook■ What is co
Page 3 and 4: Thank you for choosing Personal Com
Page 5 and 6: Your member ID card provides you wi
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Page 9 and 10: No matter where you go, your member
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Page 13 and 14: Each year, CareFirst publishes a li
Page 15 and 16: The information provided in this se
Page 17 and 18: What is the definition of a “Qual
Page 19 and 20: As a result of legislation passed i
Page 21 and 22: 1.2.3.4.5.6.Subscriber’s Legal Na
Page 23 and 24: PAGE 1 PLEASE DIRECT INQUIRIES TO:D
Page 25 and 26: Receive valuable discounts on presc
Page 27: Better hearing enriches your qualit
Page 31 and 32: The Health Insurance Portability an
Page 33 and 34: What should I do when I have questi
Page 35 and 36: Adult Physical Exams 2-3Adult Preve

Personal Comp Member Handbook - CareFirst BlueCross BlueShield

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