BCN Advantage and your primary care physician are interested in your satisfaction with the services you receive as a member. If you have a problem or concern about your care, we encourage you to discuss this with your primary care physician first. Often your primary care physician can correct the problem to your satisfaction. You are always welcome to call our Customer Service Department with any questions or problems you may have.
Should you not be able to resolve your concern through your doctor or Customer Service, we have additional procedures in place that protect your rights and help resolve your problems.
Call Customer Service for a report of the aggregate number of grievances, appeals and exceptions filed with BCN Advantage.
At any point during the complaint process, you may submit any information or evidence concerning the complaint to assist BCN Advantage in our investigation. You may file a complaint or appeal verbally or in writing. Complaints will not be accepted through email. You have 60 calendar days from the date of the condition, situation, event or issue that caused a problem to file a complaint with BCN Advantage. There are no fees or costs associated with filing a complaint.
For a detailed explanation of your rights to complain or appeal a decision, see the chapter "What to do if you you have a problem or complaint" of your Evidence of Coverage booklet.
This is the type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you, or what we will pay for a service.
An appeal is a reconsideration of an adverse organization determination or adverse coverage determination regarding the health care services or a prescription drug that you believe you are entitled to receive, including delay in providing, arranging for or approving the health care services or drug (such that a delay would adversely affect your health), or on any amounts you must pay for a service.
Upon request and where appropriate, BCN Advantage will reconsider an adverse organization determination or adverse coverage determination. If any portion of the request remains denied, that reconsidered decision will automatically be forwarded to an independent review entity (IRE), except in the case of Part D appeals. For a Part D appeal the member must request a review by the independent review entity, in writing, within 60 calendar days from the date that we notify you of our denial. Additional review is available in the form of a hearing before an Administrative Law Judge (ALJ); the Medicare Appeals Council (MAC), or by a federal court (judicial review).
This type of complaint refers to any expression of dissatisfaction to BCN Advantage, a provider, a facility or a Quality Improvement Organization (QIO), whether orally or in writing. Complaints may include concerns about how providers or BCN Advantage operate, such as: waiting times; the behavior of a physician, pharmacy, office staff, or BCN Advantage personnel; the adequacy of facilities; the respect paid to you; or claims regarding the right to receive services or payment for services you have already received.
A complaint could be either a grievance or an appeal, or a single complaint could include both. Every complaint will be handled under the appropriate grievance or appeal process.
BCN Advantage has made a coverage determination when it makes a decision about the prescription drug benefits you can receive under the plan, and the amount you must pay for the drug. A coverage determination is the initial decision made by or on behalf of BCN Advantage regarding a prescription drug to which you believe you are entitled.
An appeal will be expedited and a decision made within 72 hours if a physician, orally or in writing, supports that the standard time frame for an appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function.
The following are examples of disputes that are subject to the BCN Advantage expedited appeals process:
Any coverage determination made within 72 hours of a request for a prescription drug is an expedited (fast) coverage determination. This generally occurs when the decision not to provide the drug could potentially jeopardize your life or health or your ability to regain maximum function.
An expedited (fast) grievance is a complaint that BCN Advantage has refused to expedite an organization determination, coverage determination or reconsideration. You can also file an expedited grievance if BCN Advantage took an extension on the time needed to make an organization determination, coverage determination or appeal.
Also called a fast decision or 72-hour decision, an expedited organization determination is any organization determination made within 72 hours of a request for a service or continuation of a service. This generally occurs when the decision not to provide or continue the approval of a service could potentially jeopardize your life or health or your ability to regain maximum function.
Formulary exceptions ensure that you have access to medically necessary Part D drugs that are not included in our formulary, a list of drugs provided by BCN Advantage. They also permit you to request an exception to a quantity or dose limit or a requirement that you try another drug before we will pay for the requested drug.
A type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of care. This type of complaint does not involve payment or coverage disputes.
Any complaint or dispute, other than one involving an adverse organization determination or adverse coverage determination, expressing dissatisfaction with the manner in which BCN Advantage or one of our providers gives health care services.
Types of complaints that might fall into the grievance category include, but are not limited to:
BCN Advantage has made an organization determination when it, or one of its providers, makes a decision about Medicare Advantage services or payment that you believe you should receive.
Any decision made by or on behalf of BCN Advantage regarding payment or services to which you believe you are entitled.
A QIO is comprised of practicing doctors and other health care experts under contract by the federal government to monitor and improve the care given to Medicare members. QIOs review complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare managed care plans and ambulatory surgical centers. QIO's also review continued stay denials in acute inpatient hospital facilities.
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your copayment depends on which drug tier your drugs are in. You can ask us to make an exception for medications that are in Tier 3 (Non-preferred brand drugs).
This permits you to obtain a non-preferred drug at the cost-sharing amount applicable to drugs on the preferred tier.
This is the first step in the appeal process. BCN Advantage or an independent review entity may reevaluate an adverse organization determination or adverse coverage determination, the findings upon which it was based and any other evidence submitted or obtained.
Reconsideration will be expedited if a physician, orally or in writing, supports that the standard time frame for an appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function. When expedited, a decision will be made within 72 hours of a request for a service or continuation of a service, or a request for a prescription drug.
This is the first step in the appeal process. BCN Advantage or an independent review entity may reevaluate adverse coverage determinations, the findings upon which it was based and any other evidence submitted or obtained.
A redetermination will be expedited if a physician, orally or in writing, supports that the standard time frame for an appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function. When expedited, a decision will be made within 72 hours of a redetermination request for a prescription drug, otherwise a decision will be rendered within seven days.
Review, status and decision of complaint by the Appeals and Grievance Unit
To submit a complaint, or check the status of a complaint, you or someone properly authorized to act on your behalf, must submit a statement of the problem to the Appeals and Grievance Unit in the Customer Service Department at the address or phone number listed below.
Blue Care Network
P.O. Box 284
Southfield, Michigan 48086-5043
Hours are 8 a.m. to 8 p.m., seven days a week Eastern time
Grievances will be accepted verbally and/or in writing. Appeals are accepted orally or in writing to the address and phone number listed above. BCN Advantage will accept any information or evidence concerning the complaint. In the case of an expedited appeal, the opportunity to present evidence is limited by the 72-hour timeframe for making the decision. Therefore, you may request a 14-calendar day extension if you feel that you will need additional time.
If your complaint is a grievance, the Appeals and Grievance Unit will review your grievance and provide written notice of our decision within 30 calendar days, or 24 hours for expedited grievances, unless an extension is required.
If your complaint is an appeal, the Appeals and Grievance Unit will review your appeal and provide written notice of our decision within 30-calendar days for standard requests for services, 60 days for standard requests for payment, seven days for standard requests for Part D benefits, or 72 hours for expedited requests for services and Part D benefits, unless an extension is required.
We will provide upon request and free of charge all relevant documents and records relied upon in reaching our decision.
Disenrolling from BCN Advantage
Disenrollment from BCN Advantage means ending your membership in BCN Advantage. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):
You have the right to make a complaint if we ask you to leave BCN Advantage. If we ask you to leave BCN Advantage, we will tell you our reasons in writing and explain how you can file a complaint against us if you want to.
See your Evidence of Coverage for more information on disenrolling.
Potential for contract termination
Blue Care Network's contract with the Centers for Medicare and Medicaid Services is renewed annually, and the availability of coverage beyond the end of the current contract year is not guaranteed.
Complaint and appeal information
You may contact Customer Service for reports on the number of complaints, appeals and exceptions associated with BCN Advantage.
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