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When You Have a Complaint The following explains what to do when you don't agree with one of our decisions or when you have a complaint about our service, health plan rules, waiting times to get appointments, after-hours access to your doctor, the service at a doctor's office or a doctor's care. You may get assistance in any of the following ways. At any time, you may call the Vermont Division of Health Care Administration for help at (800) 631-7788 or (802) 828-2900. Instructions to follow when you have a complaint about Mental Health or Substance Abuse Treatment can be found below. Complaint (Inquiry) to Customer Service Our customer service team can solve most problems. We encourage you to contact customer service before filing a grievance because it may save you time. Contact us at the number on the back of your I.D. card and we will review your complaint. If you wish, another person—perhaps a provider—may call for you. Please have your I.D. Card handy when you call. You may also write to: Blue Cross and Blue Shield of Vermont
Claim Appeal (Grievance) You may file a grievance after a customer service review or without one. You have the right to obtain copies of all information related to your appeal. (We suggest you make a complaint to customer service first. This may save you time.) If your grievance is related to Emergency or Urgent Services, you may submit your grievance verbally. All other grievances should be submitted in writing. We provide alternatives for members who aren't able to file their grievances in writing. Call customer service at the number on the back of your I.D. card for help. (If you have a mental health or substance abuse grievance, see below.) Send your grievance to: Blue Cross and Blue Shield of Vermont For a grievance related to medical care not yet rendered, we will complete the review and send you notice of our decision within 30 calendar days of receiving your request for review. For a grievance related to medical care you have already received, we will complete the review and send you notice of our decision within 60 calendar days of receiving your request for review. If your grievance involves a request for Emergency or Urgent Services, we will review it and notify you of our decision within 72 hours of receiving your request. For reviews not related to medical care, we will notify you of our decision within 30 days of receiving your request. For all other reviews, we will notify you of our decision within 60 days of receiving your request. Notes:
Voluntary Appeal of Grievance Decision If you are not satisfied with the outcome of the grievance, you may file an appeal. The appeal is voluntary and is offered at no cost to you. You may also, in certain circumstances, request an external appeal with the State of Vermont by calling (800) 631-7788 or (802) 828-2900. If you choose to file a voluntary appeal, you must do so within 90 days after you receive our grievance decision. If your appeal involves a request for Emergency or Urgent Services, you may submit your appeal verbally. All other appeals should be submitted in writing. We provide alternatives for members who aren't able to file their grievances in writing. Give as much information as you can, including what happened when you took the steps above. If needed, we will help you with your appeal. Mail your appeal to: Blue Cross and Blue Shield of Vermont If your appeal involves a request for Emergency or Urgent Services, we will review it and notify you of our decision within two calendar days of receiving your request for an appeal. For all other reviews, we will notify you of our decision within 30 days of receiving your request for appeal. Notes: If you do not take advantage of the voluntary second level of appeal, the Plan waives its right to assert that you failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to the voluntary level of appeal. If you choose to take advantage of the voluntary second level of appeal, the Plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending. After you receive our decision, in certain circumstances, you may request an external appeal with the State of Vermont by calling (800) 631-7788 or (802) 828-2900. Mental Health and Substance Abuse Customer Service Complaint (or Inquiry) If you have a complaint about mental health or substance abuse care that was denied, call our customer service department at (888) 882-3600. The customer service team can solve most problems. You may also file an appeal. Mental Health and Substance Abuse Claim Appeal (Grievance) You may file a grievance after a customer service complaint. Or you may file an appeal right away. (We suggest you make a complaint to customer service first. This may save you time.) You have the right to obtain copies of all information related to your appeal. If you have an Emergency Medical Condition or require Urgent Services, we will notify you of our decision within 24 hours of receiving your request. On other appeals about mental health or substance abuse health care we will send you notice of our decision in writing within 10 calendar days of receiving your request. If your appeal is about service (not actual health care), we will resolve it within 30 calendar days of receiving your request. You must submit your appeal within 180 days of receiving our denial. You may submit an appeal in writing or by phone. Send written appeals to: Magellan Health Services Notes: The State of Vermont has a Health Care Ombudsman's office. If you have a problem with your Plan, this office may be able to help. Call (800) 917-7787 or (802) 863-2316. By accepting your Contract, you agree to seek a decision of our grievance reviewer before taking any judicial action. After you receive our decision, you may choose to pursue a voluntary appeal of the grievance decision or, in certain circumstances, you have the right to ask the state's Independent Panel of Mental Health Care Providers to review your case. The panel is not connected to us. For more information about the Independent Panel, or to ask for a review, call (800) 631-7788 or (802) 828-2900. Voluntary Appeal of First-Level Mental Health or Substance Abuse Grievance Decision You can have a second committee review your appeal if you aren't satisfied with the first decision. You have the right to get copies of all information related to your appeal. You also have the right to participate by phone. If you are not able to participate by phone, we will make arrangements for you to participate in person. To have this review, write to: Blue Cross and Blue Shield of Vermont Independent Review Are you dissatisfied with either of our review committees' decisions? After the first review, you have the right to ask the state's Independent Panel of Mental Health Care Providers to review your case. The panel is not connected to TVHP. Or, if you choose to take advantage of our second level of review, and are still not satisfied, you can call the Independent Panel at that time and ask for a review. For more information about the Independent Panel, or to ask for a review, call (800) 631-7788 or (802) 828-2900. Vermont's Mental Health Law Vermont has a law that makes mental health and substance abuse treatment benefits equal to those for other physical problems. Your benefits comply with this law. When You Have to Pay If your appeal is denied, you must pay for services we didn't cover. Make your payment to your provider. |
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