Member Complaint/Grievance Form

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• Enter Member Information

  * Required Field

• PLEASE NOTE:
  When entering your Blue KC ID, do not enter the first three alpha characters.

  Blue KC ID (Not SS#):
  i
• Suffix:
  i
• Group ID:
  i
• Group Name:
• Member First Name: *
• Member Middle Initial:
• Member Last Name: *
• Member Address: *
• City: *
• State: *
• Zip Code: *
• Member Primary Phone Number:
  Enter a 10 digit phone number.
• Member Alternate Phone Number:
  Enter a 10 digit phone number.
• Member Email Address: *
• Provider First Name:
• Provider Last Name:
• Date of Service: *

• 

• Enter Complainant Name and/or Representative Name

• Complainant First Name:
• Complainant Last Name:
• Complainant Phone Number:
  Enter a 10 digit phone number.
• Complainant Alt Phone Number:
  Enter a 10 digit phone number.
• Representative First Name:
• Representative Last Name:
• Representative Phone Number:
  Enter a 10 digit phone number.
• Representative Alternate Number:
  Enter a 10 digit phone number.

• Inquiry #: (For Internal Use Only)

Procedures for Filing a Grievance

In keeping with our commitment to provide our members with the very best service possible, Blue Cross and Blue Shield of Kansas City has established a formal procedure for receiving and responding to your concerns.

This form is for your use in filing a formal Grievance regarding any aspect of your Blue Cross and Blue Shield of Kansas City benefit plan, including care you receive from any physician, hospital, or other healthcare professional or organization as a member of this health plan. If you have further questions about this form of the Grievance Process, please call the Customer Service number printed on the front of your Member Identification card.

The member/complainant or Representative information previously entered will be displayed.

Attach any other supporting documentation:

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To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.

You will receive a decision in writing within 60 days. Members who are part of a self-funded, multi-employer plans may see response times extend beyond that 60 day window.

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