Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements, including providing notification of service, when applicable; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination. A medical reconsideration or appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. You or your physician may file a written or verbal request for reconsideration with our Grievance and Appeals Unit. The request for reconsideration must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is requesting a medical reconsideration on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. You will receive written notification of our determination within fifteen (15) calendar days from the receipt of your request for reconsideration of a prospective, concurrent, or retrospective review. You may request an appeal if our denial was upheld during the initial reconsideration. Your appeal will be reviewed by a provider in the same or similar specialty as your treating provider. You must submit your request for an appeal within forty-five (45) calendar days of receiving of the reconsideration denial letter. You will receive written notification of our appeal determination following the same timeframes noted in the How to File a Medical Request for Reconsideration section above.
SCHOOL ACT APPEALS Where a pupil and/or parent/guardian files an appeal under the School Act (Section 11) and Board by-law of a decision of an employee covered by this Agreement, or in connection with or affecting such an employee,
How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.
