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. If your inquiry is not resolved to your satisfaction, you may file a complaint or an administrative appeal. If you wish to file a complaint or administrative appeal, you must do so within one hundred and eighty (180) calendar days from the date of notice of the claim determination. You can do so by calling our Customer Service Department at (▇▇▇) ▇▇▇-▇▇▇▇ or 1-800-639- 2227. The Customer Service Representative will log your call and the nature of the issue and attempt to resolve the problem. You may also file a complaint or administrative appeal in writing. To file a complaint or administrative appeal, you must provide the details of your complaint or administrative appeal and include the following information: • name, address, member ID number; • summary of the complaint or administrative appeal, 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 Complaint/Administrative appeal form or you can send us a letter with the information requested above. A Customer Service Representative can provide you with a Complaint/Administrative appeal form upon request. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice that the person has the authority to receive information from us on your behalf. You must sign this notice. Please mail the complaint, administrative appeal, or notice to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ You will receive an acknowledgement letter from us within ten (10) business days of the receipt of your written complaint or administrative appeal. Most verbal complaints are acknowledged by the Customer Service Representative when you make your complaint and you will not receive an acknowledgement letter. The Grievance and Appeals Unit will conduct a thorough review of your Complaint or Administrative appeal. In most cases, the combined time from our receipt of your Complaint or Administrative appeal and sending a written decision to you will not exceed sixty (60) calendar days. Your determination letter from us will provide you with information regarding our determination (decision). Blue Cross & Blue Shield of Rhode Island does not offer any further internal or external review, though you may notify the State of Rhode Island Department of Health regarding your concerns or refer to the section for Judicial Review information.
Appears in 2 contracts
Sources: Subscriber Agreement, Subscriber Agreement
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. If your inquiry is not resolved you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to your satisfactionreconsider a full or partial denial of benefits, you may file a complaint or an administrative appeal. If you wish to file a complaint or administrative appeal, you must do so within one hundred and eighty (180) calendar days from the date of notice of the claim determination. You can do so by calling please call our Customer Service Department at (▇▇▇) ▇▇▇-▇▇▇▇ or 1▇-800▇▇▇-639- 2227▇▇▇-▇▇▇▇. 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 problemCustomer 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 file a complaint or administrative appealdo so, you must provide the details of your complaint or administrative appeal and include the following information: • name, address, member ID number; • summary of the complaint or administrative appealissue, 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 Complaint/Administrative appeal form Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. A Customer Service Representative can provide you with a Complaint/Administrative appeal form upon request. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice that with your signature, authorizing the person has the authority individual to receive information from us on your behalf. You must sign represent you in this noticematter. Please mail the complaint, complaint or administrative appeal, or notice appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ You We will receive an acknowledgement letter from us within ten (10) business days of the receipt of acknowledge your written complaint or administrative appeal. Most verbal complaints are acknowledged appeal in writing or by the Customer Service Representative when you make your complaint and you will not receive an acknowledgement letter. The Grievance and Appeals Unit will conduct a thorough review of your Complaint or Administrative appeal. In most cases, the combined time from our receipt of your Complaint or Administrative appeal and sending a written decision to you will not exceed sixty (60) calendar days. Your determination letter from us will provide you with information regarding our determination (decision). Blue Cross & Blue Shield of Rhode Island does not offer any further internal or external review, though you may notify the State of Rhode Island Department of Health regarding your concerns or refer to the section for Judicial Review information.phone within ten
Appears in 1 contract
Sources: Subscriber Agreement
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 dentist did not follow Blue Cross & Blue Shield of Rhode Island’s requirements. 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 Appeal DIR DEN (09-10) How To File and Appeal A Claim 23 Customer Service Department. The Customer Service Representative will try to resolve your inquiry concern. If it is not resolved to your satisfaction, you may file a complaint or an administrative appealappeal verbally with the Customer Service Representative. If you wish to file a complaint or 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 and eighty (180) calendar days from the date of notice receiving a denial of the claim determinationbenefits. You can do so by calling our Customer Service Department at (▇▇▇) ▇▇▇-▇▇▇▇ or 1-800-639- 2227. The Customer Service Representative will log your call and the nature of the issue and attempt are not required to resolve the problemfile a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To file a complaint or administrative appealdo so, you must provide the details of your complaint or administrative appeal and include the following information: • name, address, member ID number; • summary of the complaint or administrative appealissue, • any previous contact with Blue Cross & Blue Shield of Rhode Island and Island; • a brief description of the relief or solution you are seeking; • any additional 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. You can use the member Complaint/Administrative appeal form contact a Customer Service Representative or you can send us a letter with the information requested above. A Customer Service Representative can provide you with a Complaint/Administrative appeal form upon request. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice that with your signature, authorizing the person has the authority individual to receive information from us on your behalf. You must sign represent you in this noticematter. Please mail the complaint, complaint or administrative appeal, or notice appeal to: Blue Cross & Blue Shield of Rhode Island AttentionDental Attn: Grievance and Appeals P. ▇. ▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇ You will receive an acknowledgement letter from us within ten (10) business days of the receipt of your written complaint or administrative appeal. Most verbal complaints are acknowledged by the Customer Service Representative when you make your complaint and you will not receive an acknowledgement letter. The Grievance and Appeals Blue Cross Dental Unit will conduct a thorough review of your Complaint complaint or Administrative appeal. In most cases, the combined time from our receipt of your Complaint or Administrative administrative appeal and sending a written decision respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will not exceed respond to your administrative appeal in writing or by phone within sixty (60) calendar daysdays of our receipt of your administrative appeal and all necessary documentation to conduct the review. Your The determination letter from us or phone call will provide you with information regarding our determination (decision). Blue Cross & Blue Shield of Rhode Island does not offer any further internal or external review, though you a Level 2 administrative appeal. You Appeal DIR DEN (09-10) How To File and Appeal A Claim 24 may notify the State of Rhode Island Department of Health regarding or the State of Rhode Island Office of the Health Insurance Commissioner about your concerns or concerns. Please refer to the Legal Review section below for Judicial Review more information.
Appears in 1 contract
Sources: Dental Subscriber Agreement