When you have a complaint
BCN Advantage℠ and your doctor want to ensure your satisfaction with the services you receive as a member. If you have a problem or concern about your care or medication, often your doctor can correct the problem. We encourage you to discuss this matter with your doctor first.
You’re always welcome to call our Customer Service Department with any questions or concerns. Should you not be able to resolve your concerns through Customer Service or your doctor, we have additional procedures in place that protect your rights and help resolve any problems.
Resolving grievances (complaints)
You may file a grievance (complaint) or appeal verbally, in writing or with the form "Want to file a Grievance (Complaint) or Appeal." You have 60 calendar days from the date of the condition, situation, event or issue that caused the problem to file a grievance (complaint) or appeal with BCN Advantage. There are no fees or costs associated with filing a grievance (complaint) or appeal. You should submit any information or evidence concerning the issue to assist BCN Advantage in our investigation and this can be submitted at any point during the process.
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 request you make when you want us to reconsider/change a decision. This can include services or prescription drugs that are covered and what we'll pay for those services or drugs.
An appeal is a reconsideration (medical service) of an adverse organization determination about a service or an adverse coverage determination about a prescription drug (redetermination) that you believe you are entitled to receive. Appeals may be based on a delay in providing, arranging for, or approving the health care services or a prescription drug, or any amounts you may pay for the service or drug.
An appeal will be expedited if a physician supports that the appeal would seriously jeopardize your life, health or ability to regain maximum function. A decision will be made either orally or written within 72 hours.
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.
A coverage determination is a decision about whether or not to provide or pay for Medicare Part D drugs. Coverage determination also includes what your share of the costs will be and exception requests. You have the right to ask us for an exception if you believe you need a drug that is not on our formulary, believe you should get a drug at a lower copay, or are requesting an exception to the step therapy or prior authorization requirement for a drug.
A decision about whether we'll cover a Medicare Part D prescription drug can be a "standard" coverage determination that is made typically within 72 hours. For those decisions that require documentation from the prescribing physician the time frame doesn't start until the documentation is submitted. If no documentation is submitted the request will not be approved.
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 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.
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.
An expedited grievance is a complaint that the plan has refused to accelerate. It includes an organization determination, reconsideration, redetermination or the refusal to grant a member's request for extension of a time frame to make an organization determination or reconsideration.
- Complaints regarding the timeliness, appropriateness, access and/or the setting of a provided health service, procedure or item.
- Complaints that a covered health service procedure or item during a course of treatment didn't meet accepted standards for delivery of health care.
- Difficulty reaching Customer Service and/or complaints about the quality of the 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.)
- Complaints regarding the timeliness, appropriateness, access and/or setting of a network pharmacy or the cleanliness/condition of a pharmacy.
- Problems with how long you have to spend waiting on the phone or in a pharmacy.
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.
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your copay 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.
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.
BCN Advantage Grievance and Appeals Unit — C248
Blue Care Network
P.O. Box 284
Southfield, Michigan 48086-5043
Hours are 8 a.m. to 8 p.m., Monday through Friday, with weekend hours Oct. 1 to Feb. 14.
Grievances and appeals are accepted written or orally to the address and phone number listed above or through the online form "Want to file a Grievance (complaint) or Appeal." 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 more 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 for standard, 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 might leave BCN Advantage because you have decided that you want to leave. You can do this for any reason. However, there are limits to when you may leave and how often you can make changes, what your other choices are for receiving Medicare services, and how you can make changes.
There are also a few situations where you would be required to leave. For example, you would have to leave BCN Advantage if you move permanently out of our geographic service area or if BCN Advantage leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.
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.
Medicare Form to File Drug Appeal
You may also file an appeal to us using the Medicare form at this link: http://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/downloads/ModelCoverageDeterminationRequestForm.pdf
H5883_BCNAdvantage Web 6.0 CMS Approved 11132013