Step 2: Review and decision by BCN grievance panel
If you appeal from Step One, Blue Care Network's Step Two Member Grievance Panel will review and reconsider the determination made at Step One. You, or someone authorized by you in writing, may present the grievance in person or by telephone conference to the Step Two Member Grievance Panel.
For preservice claims (claims that must be decided before a member is afforded access to health care) and postservice claims (claims for a benefit involving the payment or reimbursement of the cost for medical care that has already been provided), notification of the Step Two grievance resolution will be sent to you within 15 calendar days of receiving your notice to appeal. If the grievance pertains to a clinical issue, the grievance will be forwarded to an independent medical consultant within the same or similar specialty for review. For postservice claims only, if BCN needs to request medical information, an additional ten business days will be added to the resolution time.
If an adverse determination is made, a written statement in plain English will be sent within five calendar days of the panel meeting, but not longer than 15 calendar days after receipt of the request for review. Written confirmation will contain the reasons for the adverse determination, the next step of the grievance process and the form to request an external grievance review. Upon request, we will provide, free of charge, all documents and records used to reach our determination.
page modified 04/23/2008