2013 Individual plan coverage

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. Appeals may be based on delay in providing, arranging for or approving the health care services or drug (when a delay would adversely affect your health), or on any amounts you must pay for a service.

Upon request, 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, 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; the Medicare Appeals Council, 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, 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:

• Outpatient surgery that you feel is necessary and has been scheduled
• Referral to a specialist for acute care services
• Termination of acute care services
• A determination not to provide or to discontinue services or drugs that may potentially jeopardize your life or health or your ability to regain maximum function

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:

• The timeliness, appropriateness, access to, and/or setting of a provided health service, procedure or item
• Complaints regarding the timeliness, appropriateness, access to, and/or setting of a network pharmacy
• Cleanliness or condition of pharmacy
• Problems with how long you have to spend waiting on the phone or in the pharmacy
• Belief that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care
• Refusal to expedite an organization determination or reconsideration, or taking an extension to organization determination or reconsideration time frames
• Refusal to expedite a coverage determination or reconsideration, or taking an extension to a coverage determination or reconsideration time frames
• Difficulty reaching Customer Service and/or complaints about the quality of customer service provided by BCN Advantage
• Change in premium or cost-sharing arrangements from one contract year to the next
• Involuntary disenrollment from the health plan (for non-payment of premium and/or member misconduct)

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 2 (non-preferred generic drugs) and Tier 4 (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, 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, otherwise, a decision will be rendered within 30 days for a pre-service request or 60 days for a post-service request.

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 7 days.

BCN Advantage Grievance and Appeals Unit — C248
Blue Care Network
P.O. Box 284
Southfield, Michigan 48086-5043

Telephone: 1-800-450-3680
TTY: 711
Fax: 1-888-458-0716
Hours are 8 a.m. to 8 p.m., seven days a week Eastern time