Appeals and Grievances

About the Appeals Process

Members and their treating providers may participate in the appeal process, which is described in detail in the Health Coverage Appeal Information Packet, a separate document provided to you. You can print an additional copy of the Health Coverage Appeal Information Packet from BCBSAZ here [PDF], or may call the BCBSAZ Supply Line at 602.995.6960 and request a copy by mail. Below is a summary of those issues that can be appealed, and those that are not subject to the appeal process but can be reviewed through the BCBSAZ Grievance Process.

You Can Appeal the Following Decisions:

• BCBSAZ does not approve a service that you have or your treating provider has requested, but that you have not yet received.
• BCBSAZ does not pay for a service that you have already received.
• BCBSAZ does not authorize a service or pay for a claim because it is not medically necessary.
• BCBSAZ does not authorize a service or pay for a claim because it is not covered under your insurance policy, and you believe it is covered.
• BCBSAZ does not authorize a referral to a specialist.
• Where preauthorization for a service is required by your benefit plan, BCBSAZ does not approve or deny your preauthorization request within ten business days.

Under Arizona Law, You Cannot Appeal the Following Decisions:

Although the items listed below are not appealable under state law, you and/or your authorized representative may have the right to appeal some of the following types of decisions under federal law or the right to submit a grievance through the BCBSAZ Grievance Process. Please consult the section entitled Additional Federal Rights for Group Plans for additional information regarding your appeal rights under federal law and/or the section entitled "Grievance Process".

• You disagree with BCBSAZs decision as to the amount of the BCBSAZ allowed amount.
• You disagree with how BCBSAZ is coordinating benefits when you have health insurance with more than one insurer.
• You disagree with how BCBSAZ has applied your claims to your plan deductible.
• You disagree with the amount of coinsurance or copayments that you paid.
• You disagree with BCBSAZs decision upon completion of a possible nondisclosure investigation.
• You are dissatisfied with any rate increases you may receive under your insurance.
• You believe BCBSAZ has violated any other parts of the Arizona Insurance Code.

Additional Federal Rights for Group Plans (Excluding Governmental Plans and Church Plans)

Levels 2 and 3 of Expedited Appeals and Standard Appeals and Level 2 of the Grievance Process are voluntary. If you choose not to participate in Levels 2 or 3 of the Appeals Process or Level 2 of the Grievance Process, BCBSAZ will waive its right to assert that you have failed to exhaust administrative remedies. Any statute of limitations defense or other defenses based on timeliness will be stopped while your voluntary appeal or grievance is pending.

No fees or costs may be imposed upon you as part of any voluntary level of appeal or grievance. You also have the right to request the following information from BCBSAZ before deciding to submit your claim to Levels 2 & 3: (1) information about applicable rules of Levels 2 and 3, (2) your right to representation, (3) the process for selecting the decision maker, and (4) circumstances that may affect the impartiality of the decision maker, if any. If you wish to receive this information, please call or write to the following address and telephone number:

Medical Appeals and Grievances Coordinator
Formal Appeal A116
BCBSAZ
P.O. Box 13466
Phoenix, AZ 85002-3466
Phone:(602) 864-5630
Fax: (602) 864-5858

You will have the opportunity to submit written comments, documents, or other information in support of your appeal or grievance, and you will have access to all documents that are relevant to your claim. Your appeal or grievance will be conducted by a person different from the person who made the initial decision. No deference will be afforded to the initial determination.

If your appeal involves a medical judgment question, BCBSAZ will consult with an appropriately qualified health care practitioner with training and experience in the field of medicine involved. An appropriately trained health care practitioner means a physician trained in the general practice of medicine who will consult with a specialist if deemed necessary in his or her professional judgment. If a health care professional was consulted for the initial determination, a different health care professional will be consulted on appeal. Upon request, BCBSAZ will provide you with the identification of any medical expert whose advice was obtained on behalf of the plan in connection with your appeal.

These Appeal & Grievance rights are in addition to your rights to challenge BCBSAZs decision in court, including, but not limited to bringing legal action under Section 502(A) of the Employee Retirement Income Security Act of 1974 (ERISA). You and your ERISA plan may have other voluntary alternative dispute resolution options in addition to the Appeals and Grievance Processes described in this benefit plan booklet, such as mediation. One way to find out what may be available is to contract your local U. S. Department of Labor Office. You may also be able to obtain information from your group benefits administrator.

Levels of Appeal

There are two types of appeals: (1) Expedited Appeal for urgent matters, and (2) Standard Appeal. Each type of appeal has three levels of review. The Expedited Appeals operate similarly to Standard Appeals, except that Expedited Appeals are processed much faster because of the patients condition.

Expedited Appeal	Standard Appeal
(for urgently needed services you have not yet received)	(for non-urgent services or denied claims)
Level 1 Expedited Medical Review	Level 1 Informal Reconsideration
Level 2 Expedited Appeal	Level 2 Formal Appeal
Level 3 Expedited External Independent Review	Level 3 External Independent Review

Expedited Appeal

Level 1 - Expedited Medical Review

The first level of Expedited Appeal is Expedited Medical Review, which is available only when BCBSAZ or Biodyne denies a request for a covered service that has not yet been provided (a precertification request). Expedited Medical Review requires your physician to certify orally or in writing that proceeding with the Standard Appeal process (Informal Reconsideration, Formal Appeal and External Independent Review) could seriously jeopardize your life, health or ability to regain maximum function or subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. BCBSAZ or Biodyne must notify you of its decision regarding an Expedited Medical Review as soon as possible in accordance with medical exigencies, but no later than one (1) business day. In the event of a three or four day holiday weekend, BCBSAZ will notify you of its decision as soon as possible in accordance with medical exigencies, but no later than 72 hours after we receive your appeal request. For this Level 1 appeal, issues related to services provided by Biodyne are handled by Biodyne. If a service is denied, Biodyne will process the Expedited Medical Review.

Level 2 - Expedited Appeal

An Expedited Appeal is available when, following an Expedited Medical Review, BCBSAZ or Biodyne affirms a denial of a request for a covered service not yet provided (precertification request). To request an Expedited Appeal, immediately following the Expedited Medical Review, your treating provider will be required to submit to BCBSAZ a written appeal regarding the denial of the requested service not yet provided. BCBSAZ will notify you of its decision regarding an Expedited Appeal within three (3) business days.

Level 3 - Expedited External Independent Review

You may request an Expedited External Independent Review if, at the Expedited Medical Review and Expedited Appeal level, BCBSAZ affirms a denial of a request for a covered service not yet provided (precertification request). For cases involving coverage issues, the ADOI must issue a decision within two (2) business days. For cases involving issues of medical necessity, the Arizona Department of Insurance (ADOI) will select an Independent Review Organization (IRO), which will have five (5) business days to issue a decision.

Standard Appeal

Level 1 - Informal Reconsideration

If you are not eligible to participate in the Expedited Appeal process and wish to appeal the denial of a request for a covered service not yet provided (precertification request) or a denial of a claim for a service already provided, you may request an Informal Reconsideration. BCBSAZ or Biodyne must notify you of its decision within thirty (30) days. For this Level 1 appeal, issues related to services provided by Biodyne are handled by Biodyne. If a service is denied, Biodyne will provide you with information on the Level 1 process applicable to its services.

Level 2 - Formal Appeal

You may proceed to a Formal Appeal if a denial is upheld by BCBSAZ or Biodyne at the Informal Reconsideration level. BCBSAZ must notify you of its decision within thirty (30) days for an appeal of a covered service not yet provided (precertification request) and sixty (60) days for an appeal of a claim for a service already provided.

Level 3 - External Independent Review

You are not responsible for the costs of any External Independent Review. You may request an External Independent Review following an Informal Reconsideration and Formal Appeal. For appeals involving medical necessity issues, the ADOI must select an Independent Review Organization (IRO), which has twenty-one (21) days to issue a decision regarding your appeal. For cases involving coverage issues, the ADOI must issue a decision within fifteen (15) business days. If the ADOI finds that your appeal involves a medical issue, or if the ADOI is unable to determine issues , the ADOI must issue a decision within fifteen (15) business days.