Appeals and grievances

As a Blue Shield of California Medicare Advantage or Prescription Drug Plan member, you are guaranteed your right to file a complaint if you have concerns or problems with any part of your care. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive it. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way for filing a complaint.

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage, covered services, or the care you receive. Your comments help us improve the services we provide to you. 

Download our appeals and grievances form:

• English (PDF, 122 KB)
• Arabic (PDF, 180 KB)
• Armenian (PDF, 226 KB)
• Cambodian (PDF, 163 KB)
• Traditional Chinese (PDF, 253 KB)
• Simplified Chinese (PDF, 159 KB)
• Farsi (PDF, 207 KB)
• Korean (PDF, 205 KB)
• Russian (PDF, 213 KB)
• Spanish (PDF, 99 KB)
• Tagalog (PDF, 121 KB)
• Vietnamese (PDF, 169 KB)

To check the status of a complaint you've already filed, and find information about what each status means, log in to your account to access your grievance status page. 

There are two types of complaints you can make. The type of complaint you file depends on your situation.
 

Appeals

The process for making an appeal with a Blue Shield of California Medicare plan

An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made. This can be about what services and/or drugs are covered for you or how much we will pay for a service and/or drug.

You must file the appeal request within 60 calendar days from the date included on the organizational determination notice (denial letter or coverage determination). We may give you more time if you have a good reason for missing the deadline.

To ask for a standard appeal, you, your prescribing doctor, or your appointed representative must send a written appeal request stating the nature of the complaint to the Blue Shield of California Medicare Appeals and Grievances department.

There are a few different types of decisions we can make regarding your appeal.

For plans with medical benefits:

• For a decision about payment for services you already received: After we receive your appeal, we have 60 calendar days to reconsider our decision. If we find in your favor, we must issue payment within 60 calendar days of the date of receipt of your appeal request.
• For a standard decision about authorizing medical care: After we receive your appeal, we have up to 30 calendar days to make a decision but will make it sooner if your health condition requires.
• For a standard decision about Part B drugs: After we receive your appeal, we have up to seven calendar days to make a decision but will make it sooner if your health condition requires.

For prescription drug plan: 

• For a decision about payment for Part D prescription drugs you already received: After we receive your appeal, we have 14 calendar days to make a decision. If we find in your favor, we have 30 days from the date of receipt of your appeal request to issue payment.
• For a standard decision about Part D prescription drugs: After we receive your appeal, we have up to seven calendar days to make a decision but will make it sooner if your health condition requires.

Requesting a fast appeal

If you or your doctor believes that waiting for a standard appeal decision could seriously harm your health or ability to function, you may ask for an expedited fast appeal. 

To ask for an expedited fast appeal, you, your doctor, other prescriber, or authorized representative must call, fax, or write to us at the numbers or address listed below. If you are given an expedited fast appeal, we will give you our decision within 72 hours after receiving the request. We will give you the decision sooner if your health condition requires us to.

Making a decision on your appeal

We may extend the timeframe of your appeal by up to 14 calendar days if you request an extension or if we justify a need for additional information and the delay is in your best interest. If we do not give you our decision within the appropriate appeal timeframe, your request will automatically be forwarded to an independent organization who will review your case.

If we deny your medical appeal, we will automatically forward your case to an independent review entity to review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets the minimum requirement. You will be notified of your appeal rights if this happens.

There is another special type of appeal that applies only when coverage will end for Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facilities (CORF) services. If you think your coverage is ending too soon, you can appeal directly and immediately to Health Services Advisory Group, which is the Quality Improvement Organization in the state of California. 

If you get the notice two days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice. If you get the notice and you have more than two days before your coverage ends, then you must make your request no later than noon of the day before your Medicare coverage ends.
 

Grievances

A grievance is the type of complaint you make if you have any other type of problem with a Blue Shield of California Medicare plan or one of our providers. For example, you would file a grievance if you have a problem with:

• The quality of your care
• Waiting times for appointments
• The way your doctors or others behave
• Being able to reach someone by phone or get the information you need
• The cleanliness or condition of a doctor's office.

Our grievance process consists of two steps:

Step 1: File a grievance

To begin the process, call a Customer Service representative within 60 days of the event and ask to file a grievance. You may also file a grievance in writing within 60 days of the event by sending it to:

 Blue Shield of California 
Medicare Appeals and Grievances
P.O. Box 927
Woodland Hills, CA  91365-9856

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the timeframe by up to 14 days if you ask for the extension. We may also extend the time if we justify a need for additional information and the delay is in your best interest.

If you ask for a "fast grievance" because we decided not to give you a fast decision or fast appeal, or because we asked for an extension on our initial decision or fast appeal, we will forward your request to a Medical Director who was not involved in our original decision. We may ask if you have additional information that was not available at the time you requested a fast initial decision or fast appeal.

The Medical Director will review your request and decide if our original decision was appropriate. We will notify you of our decision within 24 hours of your request for a fast grievance.

Step 2: Grievance hearing

If you are not satisfied with this resolution, you may make a written request to Blue Shield of California Medicare Appeals & Grievances for a Grievance Hearing. Within 31 days of your written request, we will assemble a panel to hear your case. You will be invited to attend the hearing, which includes an uninvolved physician and a representative from the Appeals and Grievance Resolution Department. You may attend in person or by teleconference. After the hearing, we will send you a final resolution letter.
 

Filing a grievance with our plan

If you have a complaint, please fill out our Appeals and Grievances Form online. We will mail you a written outcome when our review of your request is completed. We will contact you directly if additional information is needed to process your request.

You can also call us to file a complaint by calling:

Medicare Advantage Prescription Drug Plan members:

  (800) 776-4466 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round

Blue Shield Dual Special Needs Plans (D-SNP) members:

  (800) 452-4413 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round

Blue Shield Medicare Prescription Drug Plan members:

  (888) 239-6469 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round

We will try to resolve your complaint over the phone. If you ask for a written response, we will respond in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.

If you are contacting us by fax or by mail, please download and complete a  Blue Shield of California Appeals and Grievances Form

 Blue Shield of California Medicare Appeals and Grievances
P.O. Box 927
Woodland Hills, CA  91365-9856

 Fax: (916) 350-6510

Exceptions, appeals and grievances in your Evidence of Coverage

Following are grievance forms for Blue Shield Medicare Advantage plans. For more details on exceptions, appeals, and grievances, please refer to your plan’s Evidence of Coverage. See chapter nine for MAPD plans (PDF, 497 KB). See chapter seven for PDP plans (PDF, 314 KB).

Show all plan Evidence of Coverage documents

Medicare complaint forms

You can provide feedback directly to Medicare about your Medicare health or drug plan with the Medicare Complaint form.

Waiver of Liability Statement (WOL), English (PDF, 44 KB)

To view PDF documents, you’ll need Adobe Reader.

This information is not a complete description of benefits. Contact Customer Service at the number on your member ID card for more information.