Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because: the services were excluded from coverage; we failed to make payment (in whole or part) for a service; we determined that you were not initially eligible for coverage ; we determined that you were not eligible for coverage (for example, a rescission of coverage occurred); you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or other limitation on an otherwise covered benefit. How to File a Complaint or Administrative Appeal If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information: name, address, member ID number; summary of the issue, any previous contact with Blue Cross & Blue Shield of Rhode Island; a brief description of the relief or solution you are seeking; any more information such as referral forms, claims or any other documentation that you would like us to review; the date of incident or service; and your signature. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shie...
Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because: • the services were excluded from coverage; • we failed to make payment (in whole or part) for a service; • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred); • you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or • other limitation on an otherwise covered benefit.
Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the services were excluded from coverage or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements. How to File a Complaint or Administrative Appeal If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department at (000) 000-0000 or 0-000-000-0000. The Customer Service Representative will log your call and the nature of the issue and attempt to resolve your concern. If your concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file an administrative appeal, you must do so within 180 days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information: • name, address, member ID number; • summary of the issue, any previous contact with Blue Cross & Blue Shield of Rhode Island and a brief description of the relief or solution you are seeking; • any additional information such as referral forms, claims or any other documentation that you would like us to review; • the date of incident or service; and • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative ...
