You must file a claim within two years of the date you received the covered service. Blue Cross and Blue Shield will not have to provide coverage for services and/or supplies for which a claim is submitted after this two-year period.
Timeliness of Claim Payments
Within 30 calendar days after Blue Cross and Blue Shield receives a completed request for coverage or payment, Blue Cross and Blue Shield will make a decision. When appropriate, Blue Cross and Blue Shield will make a payment to the health care provider (or to you in certain situations) for your claim to the extent of your coverage in this health plan. Or, Blue Cross and Blue Shield will send you and/or the health care provider a notice in writing of why your claim is not being paid in full or in part.
Missing Information
If the request for coverage or payment is not complete or if Blue Cross and Blue Shield needs more information to make a final determination for your claim, Blue Cross and Blue Shield will ask for the information or records it needs. Blue Cross and Blue Shield will make this request within 30 calendar days of the date that Blue Cross and Blue Shield received the request for coverage or payment. This additional information must be provided to Blue Cross and Blue Shield within 45 calendar days of this request.
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Missing Information Received Within 45 Days. If the additional information is provided to Blue Cross and Blue Shield within 45 calendar days of Blue Cross and Blue Shield’s request, Blue Cross and Blue Shield will make a decision within the time remaining in the original 30-day claimdetermination period. Or, Blue Cross and Blue Shield will make the decision within 15 calendar days of the date that the additional information is received by Blue Cross and Blue Shield, whichever is later.
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Missing Information Not Received Within 45 Days. If the additional information is not provided toBlue Cross and Blue Shield within 45 calendar days of Blue Cross and Blue Shield’s request, the claim for coverage or payment will be denied by Blue Cross and Blue Shield. If the additional information is submitted to Blue Cross and Blue Shield after these 45 days, then it may be viewed by
Blue Cross and Blue Shield as a new claim for coverage or payment. In this case, Blue Cross and Blue Shield will make a decision within 30 days as described previously in this section.
WORDS IN ITALICS ARE EXPLAINED IN PART 2.
Part 10
Grievance Program
You have the right to a full and fair review when you disagree with a decision that is made by Blue Cross and Blue Shield to deny coverage or payment for services; or you disagree with how your claim was paid; or you have a complaint about the care or service you received from Blue Cross and Blue Shield or from a health care provider who participates in your health care network; or you are denied coverage in this health plan or your coverage is cancelled or discontinued by Blue Cross and Blue Shield for reasons other than nonpayment of premium.
Inquiries and/or Claim Problems or Concerns
Most problems or concerns can be handled with just one phone call. (See page 3.) For help to resolve a problem or concern,you should first call the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. A customer service representative will work with you to help you understand your coverage or to resolve your problem or concern as quickly as possible.
When resolving a problem or concern, Blue Cross and Blue Shield will consider all aspects of the particular case. This includes looking at: all of the provisions of this health plan; the policies and procedures that support this health plan; the health care provider’s input; and your understanding and expectation of coverage by this health plan. Blue Cross and Blue Shield will use every opportunity to be reasonable in finding a solution that makes sense for all parties. Blue Cross and Blue Shield may use an individual consideration approach when it is judged to be appropriate. Blue Cross and Blue Shield will follow its standard guidelines when it resolves your problem or concern.
If after speaking with a Blue Cross and Blue Shield customer service representative, you still disagree with the decision that is given to you, you may request a review through the Blue Cross and Blue Shield
internal formal grievance program. You may also request this type of review if Blue Cross and Blue Shield has not responded to you within three working days of receiving your inquiry. If this happens, Blue Cross and Blue Shield will notify you and let you know the steps you may follow to request an internal formal grievance review.
Formal Grievance Review
Internal Formal Grievance Review How to Request a Grievance Review
To request a formal review from the Blue Cross and Blue Shield internal Member Grievance Program, you (or your authorized representative) have three options.
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Write or Fax. The preferred option is for you to send your grievance in writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Or, you may fax your grievance to 1-617-246-3616. Blue Cross and Blue Shieldwill let you know that your request was received by sending you a written confirmation within 15 calendar days.