Grievance and Appeals Process - Blue Shield of California · Grievance and Appeals Process ... CalPERS members enrolled in the NetValue HMO plan will have access to a smaller number

Grievance and Appeals Process Blue Shield has established a grievance procedure for receiving, resolving and tracking Members’ grievances with Blue Shield.

For all services other than mental health and substance abuse services If a member is not satisfied with the Member Services department’s response to his or her inquiry, the member, the member’s provider or representative may submit a grievance by either: 1) calling or writing to the Member Services department and requesting that they review the initial response or, 2) submitting a completed “Grievance Form.” The member may request this form from the Member Services department by calling (800) 334-5847, or the member can submit his or her grievance online by visiting our Web site at bluelshieldca.com. The completed form should be submitted to the Member Services department at the address below. Blue Shield will acknowledge receipt of a written grievance within five calendar days.

Members can receive this form Online at blueshieldca.com under ‘find a form’ or by contacting Member Services at (800) 334-5847, Monday – Friday, 7:00 a.m. to 7:00 p.m.

Completed form should be sent to: Blue Shield Attention: Member Services P.O. Box 272520 Chico, CA 95927-2520

The grievance system allows a member to file a grievance for at least 180 days following any incident or action that is the subject of the enrollee’s dissatisfaction. Grievances are resolved within 30 days.

For all mental health and substance abuse services If the telephone or written inquiry to the mental health services administrator (MHSA) does not resolve the question to the member’s satisfaction, the member may submit a grievance by either 1) calling the MHSA’s Customer Service department at the number listed below and requesting that they review the initial response or, 2) submitting a grievance to the MHSA in writing or by telephone at the number listed below. If the member wishes, the MHSA’s service staff will assist in completing the grievance form. Completed grievance forms can be mailed to the MHSA at the address provided below. The MHSA will acknowledge receipt of a written grievance within five calendar days.

MHSA address: U.S. Behavioral Health Plan, California Attn: Customer Service P.O. Box 880609 San Diego, CA 94168

Grievances are resolved within 30 days.

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Health Benefits Officer Resource Guide • L-1

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External Independent Medical Review If a member’s grievance involves a claim or services for which coverage was denied by Blue Shield or by a contracting provider in a whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the Friedman-Knowles Experimental Treatment Act of 1996), the member may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. The member normally must first submit a grievance to Blue Shield and wait for at least 30 days before he or she requests external review; however, if the member’s matter would qualify for an expedited decision as described in the Evidence of Coverage or involves a determination that the requested service is experimental/investigational, the member may immediately request an external review following receipt of notice of denial. The member may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Member Services. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have their records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. Members may choose to submit additional records to the external review agency for review. There is no cost to the member for this external review. The member and his or her physician will receive copies of the opinions of the external review agency. This external review will be conducted in accordance with the same normal and expedited grievance time frames stated above. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided. This external review process is in addition to any other procedures or remedies available to members and is completely voluntary on their part; they are not obligated to request external review. However, failure to participate in external review may cause them to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Member Services at (800) 334-5847.

Appeal procedure following disposition of plan grievance procedure If no resolution of the member’s complaint in achieved by the internal grievance process described above, the member has several options depending on the nature of his or her complaint.

1. Eligibility issues. Refer these matters directly to CalPERS. Contact the CalPERS Health Benefit Services Division at P.O. Box 942714, Sacramento, CA 94229-2714, or telephone (888) CalPERS (225-7377).

2. Coverage issues. A coverage issue concerns the denial or approval of healthcare services substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the current Evidence of Coverage. It does not include a



continued from previous page plan or contracting provider decision regarding a disputed healthcare service. If the member is dissatisfied with the outcome of Blue Shield’s internal grievance process or if he or she has been in the process for 30 days or more, he or she may request review by the Department of Managed Health Care, or may request an administrative hearing before the CalPERS Board of Administration, or the member may choose small claims court if the coverage dispute is within the jurisdictional limits of small claims court.

3. Malpractice. Member must proceed directly to court. 4. Bad faith. Member must proceed directly to court. 5. Disputed healthcare service issue. A disputed healthcare service issue concerns any

healthcare service eligible for coverage and payment under the current Evidence of Coverage that has been denied, modified or delayed in whole or in part due to a finding that the service is not medically necessary. A decision regarding a disputed healthcare service relates to the practice of medicine and is not a coverage issue, and includes decisions as to whether a particular service is experimental or investigational.

If the member is dissatisfied with the outcome of Blue Shield’s internal grievance process or if he or she has been in the process for 30 days or more, they may request an independent medical review from the Department of Managed Health Care. If the member is dissatisfied with the outcome of the independent medical review process, he or she may request an administrative hearing before the CalPERS Board of Administration, or they may proceed to court.

CalPERS administrative appeal process Only issues of eligibility and coverage issues that concern the denial or approval of healthcare services substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the Evidence of Coverage may be appealed directly to CalPERS.

CalPERS staff will conduct an administrative review upon the member’s appeal of Blue Shield’s denial of coverage or the denial of a disputed healthcare issue by the Department of Managed Health Care. However, the member’s written appeal must be submitted to CalPERS within 30 days of the postmark date of Blue Shield’s letter of denial or the Department of Managed Health Care’s determination of findings.

If the dispute remains unresolved during the administrative review process, the matter may then proceed to an administrative hearing. During the hearing, evidence and testimony will be presented to an administrative law judge.

To file for an administrative hearing, the member should contact CalPERS Health Benefit Services Division, P.O. Box 942714, Sacramento, CA 94229-2714, (888) CalPERS (225-7377).




Department of Managed Health Care review The California Department of Managed Health Care is responsible for regulating healthcare service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800)334-5847 and use the health plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to the member. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number, (888) HMO-2219, and a TDD line, (877) 688-9891, for the hearing impaired. The Department’s Web site, http://hmohelp.ca.gov, has complaint forms, IMR application forms and instructions online.

In the event that Blue Shield should cancel or refuse to renew enrollment you or his or your dependants and you feel that such action was due to health or utilization of benefits, you or your dependants may request a review by the Department of Managed Health Care director.

Matters of eligibility should be referred directly to CalPERS the member can contact CalPERS, Health Benefit Services Division at P.O. Box 942714, Sacramento, CA 94229-2714.


Frequently Asked Questions (FAQs) What's the difference between HMO and EPO? HMO and EPO are two types of managed care plans that Blue Shield offers CalPERS members.

HMO stands for Health Management Organization. When members join our Access+ HMO, they access a network of physicians, labs and hospitals, and choose a Personal Physician from our network. Members’ Personal Physicians provide or arrange their health care and must provide authorizations or referrals if specialty care is needed. With an HMO, members generally have no annual deductibles or claim forms, and they pay an affordable copayment each time they see a physician.

EPO stands for Exclusive Provider Organization. An EPO is similar to an HMO in that members must choose service within the network of providers. Blue Shield EPO members have access to Blue Shield’s preferred providers through our PPO network. Many other healthcare professionals, including optometrists, podiatrists and home healthcare agencies, are also preferred providers.

Blue Shield’s EPO plan is offered to CalPERS members exclusively in Colusa, Mendocino, and Sierra counties.

What's the difference between Access+ and NetValue NetValue HMO CalPERS members enrolled in the NetValue HMO plan will have access to a smaller number of selected medical groups and affiliated Personal Physicians and specialists than are available in Blue Shield’s Access+ HMO plan; at a lower monthly rate. Access+ HMO Access+ HMO plan offers the same comprehensive benefits as NetValue HMO, but from a wider network of physicians for a higher monthly rate. How can members find a doctor or hospital in the Blue Shield networks? It’s easy to use our online directories to customize a search for providers. Members can see if their physician or hospital participates in our network or find a new provider by going to the “Find a Provider” section of our Web site, blueshieldca.com/calpers. They can also call Member Services at (800) 334-5847.

When they search online, members will receive a customized list of physicians or hospitals. To see detailed information, they just need to click on a physician’s name to learn about specialties, languages spoken, certification, IPA or medical group affiliations and Blue Shield health plan participation.

When can members change their Personal Physician? Members can change their Personal Physician at any time. The change will be effective the first day of the month following notice of approval by Blue Shield. To make the change, they should contact Member Services at (800) 334-5847.

How can members find a hospital or doctor outside of California? Members should go to the “Find a Provider” section of blueshieldca.com and click the “Providers Outside of California” link to search for BlueCard doctors and hospitals or call (800) 810-BLUE (2583) for a list of doctors.

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Do Access+ HMO and NetValue HMO members need a referral to see a specialist? No. They can take advantage of our Access+ Specialist option and see a specialist in the same medical group or IPA as their Personal Physician without a referral for a $30 copayment. To take advantage of this feature, their Personal Physician must belong to a medical group or IPA that offers the Access+ Specialist option.

Can Access+ HMO and NetValue HMO members visit a doctor outside of their medical group or IPA? Except in an emergency, members cannot seek coverage outside of their medical group or receive care from a hospital without prior authorization from their IPA/Medical Group or Blue Shield. For an authorization from Blue Shield, members should call Member Services.

Can an Access+ HMO and NetValue HMO member see an OB/GYN without a referral? Yes, HMO members can seek OB/GYN services from an obstetrician/gynecologist or family practice physician in the same medical group or IPA as their Personal Physician without a referral.

What is the copayment for routine gynecological exams? Members pay only $15 for a routine exam. For preventative annual women’s examination, the co-pay would be waived.

What if an Access+ HMO and NetValue HMO member is dissatisfied with the services he or she receives from a network physician? Access+ Satisfaction, Blue Shield’s member feedback program, will send the member a refund equal to the usual physician office visit copayment if an Access+ HMO member is ever dissatisfied with the service provided during an office visit with a network physician.

If a member has a child who is attending school out of state, or has a dependent who lives out of state, can the member get coverage for the dependent through Access+ HMO? Yes, Blue Shield Access+ HMO offers coverage for dependants who are out of state (in most states) through the Guest Membership program. Members can call Member Services at (800) 334-5847 for more information.

When does an Access+ HMO and NetValue HMO member need to file a medical claim? Because these members’ Personal Physicians will provide and coordinate their healthcare, they rarely have to deal with claim forms, except in the case of emergency services and out-of-area urgent services.


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What should a member do if he or she receives emergency service? If emergency services are received and expenses are incurred by the member for services other than medical transportation, the member must submit a complete claim with the emergency service record for payment to Blue Shield within one year after the first provision of emergency services for which payment is requested. If the services are not pre-authorized, Blue Shield will review the claim retrospectively for coverage.

Blue Shield will notify the member of its determination within 30 days from receipt of the claim. For additional information, members should consult their current Evidence of Coverage (EOC).

What should a member do if he or she receives urgent care outside California from a provider who is not in the BlueCard network? If out-of-area urgent service is received from a non-BlueCard provider, the member must submit a complete claim with the urgent service record for payment to Blue Shield at the address below, within one year after the first provision of urgent service for which payment is requested. The service will be reviewed retrospectively by Blue Shield and the member will be notified of its determination within 30 days of receipt of the claim. For additional information members should consult their current EOC.

How does a member file a medical claim? To file a medical claim, the member should: 1. Photocopy the itemized bill provided by the doctor or hospital. 2. Download a claim form from blueshieldca.com or contact Member Services to

have one sent. 3. Complete the claim form. 4. Send the completed form and a copy of the itemized bill to Blue Shield

P.O. Box 272540 Chico, CA 95927-2540

How long does it take to process a claim? Most Blue Shield claims are finalized within 30 days. Members can usually expect to receive notification within four to six weeks of submitting a claim.

How does a member check the status of a claim? Members should call Member Services. They’ll need to provide the date of service, name of the physician and the billed amount. Members can also go online at www.blueshieldca.com/calpers.




What should a member do when they receive a bill from a provider? Members should call Member Services. When they call, they should have their Blue Shield ID number, billing paperwork and any important information such as date(s) of treatment and physician name.

How does a member file a Grievance? Please see pages L-1 under the Grievance and Appeals Process section of this guide.

What is a drug formulary? The drug formulary is a comprehensive list of preferred drugs maintained by our Pharmacy and Therapeutics Committee for use under the Blue Shield Outpatient Prescription Drug Program, which is designed to assist physicians in prescribing drugs that are medically necessary and cost effective. The formulary is updated quarterly. If not otherwise excluded, the formulary includes all generic drugs.

Members can review the most updated drug formulary online at blueshieldca.com by clicking on “Pharmacy” on the top navigation bar. From the menu, they select “Drug Database & Formulary.” From there, they can search by a specific drug name, medical condition or drug class. Or they can download the most current formulary from the navigation bar on the right-hand side. Members can also obtain a printed copy of the Blue Shield Drug Formulary by calling Member Services at (800) 334-5847.

A non-formulary drug is any medication that is not listed in the drug formulary. CalPERS’ benefits provide coverage for non-formulary drugs at a higher non-formulary copayment. Some formulary and non-formulary medications require prior authorization for medical necessity.

Which drugs require prior authorization? Prior authorization criteria and procedures are in place for the following types of drugs: • Drugs with specialized uses • Drugs with potential for misuse or overuse • Drugs that should be limited to a maximum quantity according to the FDA-approved

indications • Medically necessary non-formulary drugs

Prior authorization means that the member’s physician must get authorization from Blue Shield’s Pharmacy Services department before a medication requiring prior authorization will be covered.




Are there other formulary restrictions? When looking up a drug in the formulary, note that some drugs have restrictions such as: • Limits on quantity covered. • Prior therapy required. (This means that the drug would be covered only after standard first-line

drug therapy has been tried.)

For drugs with quantity limits, a member’s physician will need to request prior authorization for higher quantities by calling Blue Shield Pharmacy Services at (800) 535-9481.

How much is CalPERS Blue Shield members’ prescription copayment? When CalPERS members purchase a prescription covered by Blue Shield, they’ll pay the following copayment amount for up to a 30-day supply:

Retail pharmacy $5 for generic medications $15 for formulary brand-name medications $45 for non-formulary brand-name medications*

Mail service $10 for generic medications $25 for formulary brand-name medications $75 for non-formulary brand-name medications*

Not to exceed a 90-day supply for mail order drugs which are taken over long periods of time (maintenance drugs); $1,000 out-of-pocket annual maximum

*A lower copayment for non-formulary drugs may apply subject to prior approval of the brand-name drug by Blue Shield.

Does Blue Shield provide chiropractic coverage? No, but discounted services are offered through our Mylifepath Alternative Health Discount Program with a savings of at least 25 percent off the practitioner's published fees. This program is made available through an arrangement with American Specialty Health Networks (ASH Networks) and is not a covered service of any Blue Shield health plan.


What are the steps and who are the people who work to provide you with a referral authorization? See process flow below:

Your Primary Care Physician (PCP) recommends you to a specialist.

PCP or staff will fax our courier the referral request to the assigned Referral Coordinator.

Assigned IPA/Medical Group referral Coordinator reviews referral. If the referral falls into the auto authorization category then the IPA/Medical Group Referral Coordinator can approve it.

If approved by the Utilization Board the referral is sent back to the IPA/Medical Group Referral Coordinator who will mail the authorization to the patient and the s

The requesting provider is notified within 24 hours of the Utilization Board decision.

If the Referral Coordinator can not approve the referral, it is forwarded to the Utilization Board for review. Utilization Board is a panel of physicians who meet twice a day to review such cases.

If the Referral Coordinator approves the referral, a copy of the authorization is forwarded to the appropriate specialist and mailed to the patient. Note: If patient does not receive the authorization within 7-10 days, please contact Member Services at 1-800-334-5847

pecialist.

Blue Shield member ID card Members should always present their Blue Shield Member ID card when obtaining medical services.

Members can request a new ID Card by contacting Member Services at (800) 334-5847, Monday through Friday, 7:00 a.m. to 7:00 p.m.

JANE DOE XEHJ50505555

JANE DOE Effective: 1/1/08

(909) 123-4567

Health Benefits Officer Resource Guide • N-1

BlueCard Worldwide international claim Claim form submitted for covered services received outside of the United States.

Members can receive this form online at blueshieldca.com under “forms download” or by contacting Member Services at (800)-334-5847, Monday through Friday, 7:00 a.m. to 7:00 p.m. Completed form should be sent to: Blue Shield,

Foreign Claims P.O. Box 272550 Chico, CA. 95927-2550


BlueCard Worldwide international claim Sample


CalPERS enrollment document HB-12 Form used to report all enrollment transactions.

HBO’s can find this and other CalPERS forms at: www.calpers.ca.gov

Completed form should be sent to: CalPERS Health Benefits

Services Division P.O. Box 942714 Sacramento, CA. 94229-2714


CalPERS enrollment document HB-12 Sample


Confidentiality release form This form authorizes Blue Shield to disclose personal and health information to a third party. This authorization is voluntary. Blue Shield places no conditions on our payment activities in connection with a member’s claim, their enrollment in our health plan or their eligibility for benefits because they have given this authorization. Members can choose not to sign this authorization.

Members can receive this form by contacting Member Services at (800)-334-5847, Monday through Thursday, 8:00 a.m. to 5:00 p.m. and Friday, 9:00 a.m. to 5:00 p.m. Completed form should be sent to: Blue Shield

PO Box 272520 Chico, CA 95927-2520


Confidentiality release form Sample

Health Benefits Officer Resource Guide • N7

PrimeMail Mail Service Pharmacy brochure


PrimeMail Mail Service Pharmacy Prescription form


Grievance Form Blue Shield has established a grievance procedure for receiving, resolving and tracking members’ grievances with Blue Shield. For additional information about the grievance and appeals process see pages L-1 of this guide.

Members can receive this form online at blueshieldca.com under “find a form” or by contacting Member Services at (800) 334-5847, Monday through Friday, 7:00 a.m. to 7:00 p.m. Completed form should be sent to: Blue Shield

Attention: Member Services P.O. Box 272520 Chico, CA 95927-2520


Grievance Form Sample


Guest Membership Members and their dependants may be eligible for coverage when they are out of state for 90 to 180 days. A Guest Membership coordinator will pre-qualify the member prior to sending an application.

If interested in the Guest Membership program, members should call Member Services at (800) 334-5847, Monday through Friday, 7:00 a.m. the 7:00 p.m. Completed form should be sent to: Blue Shield

Attn: HMOUSA 4203 Town Center Blvd – C2 El Dorado Hills, CA 95762


Guest Membership Sample


Personal Physician selection form for Access+ HMO and NetValue HMO members Members must select a Personal Physician within their plan service area, listed in the Blue Shield Access+ HMO Physician and Hospital Directory or in the Access+ HMO physician listing in the Find a Provider section of blueshieldca.com. New enrollees should complete this form during Open Enrollment; they may also change their Personal Physician throughout the year by filling out the same form. Members can change their Personal Physician at any time. The change will be effective the first day of the month following notice of approval by Blue Shield.

The selection or change of a Personal Physician may also be made by contacting Member Services at (800) 334-5847, Monday through Friday, 7:00 a.m. to 7:00 p.m.,

Members may also request a Personal Physician selection form from Member Services or online at www.blueshieldca.com/calpers.

The completed form should be sent to: Blue Shield

MEMBERSHIP P.O. Box 629019 El Dorado Hills, CA. 95762-9814


Personal Physician selection form for Access+ HMO and NetValue HMO members Sample


Subscriber’s statement of claim form Used when a member’s provider does not bill Blue Shield directly or when a member has received emergency or out-of-area urgent services. Members should always check with their provider to be sure that no claim has been submitted.

Members can receive this form online at blueshieldca.com under “forms download” or by contacting Member Services at (800)-334-5847, Monday through Friday, 7:00 a.m. to 7:00 p.m. Completed form should be sent to: Blue Shield P.O. Box 272540 Chico, CA. 95927-2540


Subscriber’s statement of claim form Sample


Medicare Coordinated Care Plan Members seeking information about Blue Shield’s Medicare Coordinated Care Plan should reference section 2 of their current Evidence of Coverage (EOC).

The EOC will provide members with the following information: 1. Benefit changes for the current year 2. Eligibility 3. How to use the plan 4. Rates for the Medicare Coordinated Care Plan 5. Summary of covered services 6. Benefit descriptions 7. Exclusion and limitations 8. General provisions 9. Continuation of coverage after termination of group membership 10. Payment by a third party


Health Benefits Officer Resource Guide • O-1






Regional Pricing As of January 1, 2005 premiums for CalPERS Basic HMO and PPO plans will be priced differently for public agency members to better reflect market costs according to five regions. CalPERS will continue to base the state rate on the entire CalPERS pool of both public and state agencies. Public agencies will be priced using public agency information only and their rate will closely align with what they would pay in the open market where they are located. Regional pricing will not affect state or public agency Medicare-eligible retirees.

The public agency rates charged are based on the pricing region in which the employee/annuitant resides. Thus, the subscriber residence drives the regional rate for the entire contract (subscriber and dependents). It is not determined based on the location of any providers selected.

The five public agency regions are: 1. San Francisco Bay Area/Sacramento and adjoining counties 2. Northern California counties (other than above) 3. Los Angeles/Ventura/San Bernardino counties 4. Southern California counties (other than above) 5. Out-of-state

For additional information about regional pricing please contact Blue Shield Account Management.

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Regional Pricing

Health Benefits Officer Resource Guide • P-2

Documents

Grievance and Appeals Process - Blue Shield of California · Grievance and Appeals Process ... CalPERS members enrolled in the NetValue HMO plan will have access to a smaller number