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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:
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  • Member First Name: *
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  • Member Middle Initial:
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  • Member Last Name: *
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  • Member Address: *
  •  
  • City: *
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  • State: *
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  • Zip Code: *
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  • Member Primary Phone Number:
  • Enter a 10 digit phone number.
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  • Member Alternate Phone Number:
  • Enter a 10 digit phone number.
  •  
  • Member Email Address:
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  • Provider First Name:
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  • Provider Last Name:
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  • Date of Service: *
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Enter Complainant Name and/or Representative Name

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

Explanation of Concern: *

Please attach any other supporting documentation:

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

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.

If you experience issue submitting this form, please fax or mail to:

Fax:
816-278-1920

Mail:
Blue Cross and Blue Shield of Kansas City
PO Box 417005
Kansas City, MO 54141-7005

If you have questions, call (816) 395-3558.

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Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card on this page. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Your Suffix is a two digit number located on your Member ID card. See the sample ID card on this page. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Your group number is on the front of your Member ID card. See the sample ID card on this page. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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