The Grievance Process: For Providers Effective October 1, 2008
Effective October 1, 2008
BCBSAZ contracted providers and non-contracted providers may participate in the Provider Grievance Process (the "Grievance Process"), which has two levels of review. The Provider Grievance Process is distinct from the processes for Health Coverage Appeals and Member Grievances. The Grievance Process is not intended to limit provider participation in the Health Coverage Appeal Process. Providers who are authorized to act on behalf of a member may submit a health care appeal to BCBSAZ to the extent permitted under the Health Coverage Appeal Process and ERISA.
Matters that are Subject to the Grievance Process:
The Provider Grievance Process applies to payment disputes and some non-payment disputes such as systemic or operational problems, quality assurance problems or network adequacy problems unrelated to the provider's contract status. It does not apply to situations that are subject to a Health Care Appeal.
BCBSAZ decisions to grant, deny, non-renew, terminate or amend a provider's network contract are not grievable. Disagreements between a provider and BCBSAZ about price, contractual language, or other terms of an initial or renewal contract or contract amendment are not subject to the Provider Grievance Process or any other BCBSAZ grievance or appeals process.
Grievable Issues include:
- Whether the claim was clean
- Failure to timely pay claim
- Amount paid (bundling software)
- Amount paid (other than bundling software)
- Amount or timeliness of interest payment
- Denials based on investigational or medical necessity determinations that require a provider write-off
- Adjustment request
- Network adequacy (other than the provider's contract status)
- Systemic or operational problems
Grievance (Level 1)
All Grievances must be in writing. A provider must submit a written Level 1 Grievance request to BCBSAZ within one year of the denial or other notification, or date of the occurrence if the provider did not receive notification. BCBSAZ may extend this one-year time period for good cause or if a longer period is required by state or federal law. "Good cause," as used in this section, means circumstances beyond the reasonable control of the provider, and which prevented the provider from submitting a timely grievance request.
A Level 1 Grievance request should include:
- A reference to or copy of the action with which the provider disagrees;
- A written explanation of why the provider thinks the action is wrong, and the relief the provider is requesting;
- Documentation that supports the provider's position, such as medical records, operative reports, or office notes.
BCBSAZ staff members who were not involved in the initial determination will review the grievance, including any new information submitted to BCBSAZ. The provider submitting the grievance will be notified in writing of BCBSAZ's decision within 30 days of receipt for pre-service issues and within 60 days of receipt for post-service issues.
BCBSAZ may extend the 30 or 60-day time period for up to an additional 60 days. If BCBSAZ requires an extension, BCBSAZ will notify the provider in writing prior to expiration of the initial time period.
BCBSAZ will mail all decisions to the provider's last address on file with BCBSAZ, except for providers located outside Arizona. BCBSAZ will transmit decisions for out-of-state providers to the Blue plan in the provider's home state, and that Blue plan will send the decision to the provider. The decision is deemed received on the date of delivery, if hand-delivered, or, if mailed, on the earlier of the actual date of receipt or five days after deposit in the United States mail, postage prepaid.
Grievance (Level 2)
If BCBSAZ's Level 1 Grievance resolution is not satisfactory, the provider may request a Level 2 Grievance. The Level 2 Grievance must be submitted in writing to BCBSAZ within 60 days after receipt of the Level 1 Grievance determination. A provider may extend the 60-day time period for up to an additional 60 days. If the provider requires this additional time to submit the Level 2 Grievance, the provider shall notify BCBSAZ in writing within the initial 60-day period. The Level 2 Grievance must state the reason for dissatisfaction with the prior decision, and any additional information for review. BCBSAZ will notify the provider of BCBSAZ's final decision within 60 days of the date BCBSAZ receives the provider's Level 2 Grievance. BCBSAZ may extend this 60-day time period for up to 60 days on written notice to the provider, given within the 60-day period.
Grievance Submission
Click here [PDF] to view the "Provider Appeal and Grievance Quick Reference Guide" in
this section for a listing of grievance mailing addresses by type of issue.
For provider non-payment disputes, including but not limited to systemic or operational
problems, quality assurance problems or network adequacy problems unrelated to the
provider's contract status contact:
Manager - Provider Network Relations S101
BCBSAZ
P.O. Box 13466
Phoenix, AZ 85002-3466
Telephone: (602) 864-4231
Fax: (602) 864-3141
E-mail: prvgriev@azblue.com
Click here, to file a health care appeal on behalf of the
member, and to be connected to the link that describes the BCBSAZ Health Coverage
Appeals process.
*BCBSAZ's appeals process does not apply to Federal Employee Program enrollees, members of plans offered by other Blue Cross and/or Blue Shield licensees (all of which have their own appeals procedures) or participants in a self-insured employee plan (unless that plan has adopted BCBSAZ's appeals procedures). ERISA regulations require self-funded employee plans to provide an appeal process comparable to the appeal process required by Arizona's insurance laws.
Posted to azblue.com 8-28-08