As a Blue Cross Blue Shield of Massachusetts member, you have a right to a formal review if you disagree with any decision we have made.
Effective January 1, 2016, all requests for an appeal or a grievance review must be received by Blue Cross Blue Shield HMO Blue within 180 calendar days of the date of treatment, event, or circumstance which is the cause of your dispute or complaint, such as the date you were informed of the service denial or claim denial.
When you submit a written request for a formal appeal or grievance review, you will receive written confirmation within 15 days. You will receive our written decision regarding your appeal or grievance within 30 days.
If the appeal review process results in a denial in part or full, we will explain how we reached this decision. Following a formal appeal review, you may also be eligible for an external review. If your formal appeal qualifies for an external review, we will provide for you the steps you should take to file such a request.
Your full appeal and grievance rights are listed in your Evidence of Coverage (EOC), including information on designating an authorized representative to act on your behalf through the process.
If you have questions, or would like written information, please call Member Service at the toll-free number on the front of your ID card.
Providing Fair, Quality Care
Blue Cross Blue Shield of Massachusetts is proud of its commitment to your health. That's why we base our coverage decisions on the appropriateness of medical care, services, and your benefit plan. To help ensure that you receive the highest quality and safest care:
We do not reward practitioners and other individuals for issuing denials of coverage or service
We do not reward coverage decision-makers for issuing denials or under utilization of care or services