Procedures for Filing a Grievance
Definitions
- Adverse Determination—A determination that an admission, availability of care, continued stay, or other healthcare service has been reviewed and, based upon the information provided, does not meet the requirements for Medical Necessity, appropriateness, healthcare setting, level of care or effectiveness, and payment for the requested service is therefore denied, reduced or terminated.
- Inquiry—A question or request for information or action. Usually can be resolved on initial contact with no follow-up action required.
- Complaint—An oral allegation of improper or inappropriate action, or an oral statement of dissatisfaction with covered services, post-service claims payment or policies that do not fall within the definition of Grievance.
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Grievance—A written complaint submitted by or on behalf of a member regarding:
- The availability, delivery, or quality of healthcare services, including a complaint regarding an Adverse Determination make pursuant to utilization review;
- Post-service claims payment, handling or reimbursement for healthcare services; or
- Matters pertaining to the contractual relationship between a member and Blue Cross and Blue Sheild of Kansas City, including a denial or rescission of coverage.
- Grievances must be filed within 365 days of receipt of the denial.
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Expedited Review—a Complaint or Grievance that fits the description of a Grievance, but involved a situation where the time frame of the standard Grievance procedures:
- Would seriously jeopardize the life or health of a member;
- Would jeopardize the member's ability to regain maximum function; or
- In the opinion of a physician with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the requested care of treatment.
When you are dissatisfied with your dealings with Blue Cross and Blue Shield of Kansas City, you have the right to pursue your concern through the following mechanisms:
Procedures for Filing a Grievance
You are encouraged to discuss your concerns regarding your medical care with your physician or other healthcare provider. Your customer service representative (see the phone number on your Identification card) is also available to answer questions about claims and benefits.
However, if you are not fully satisfied with the response you receive, and wish to express your concern to a higher level, you may file a formal Grievance. To file a Grievance, you may complete this form, or you may write a letter outlining as many details as possible regarding the incident in question. Your completed form or letter can be faxed to 816-278-1920, Attn: Appeals Department, or mailed to the following address:
Appeals Department
Blue Cross and Blue Shield of KC
PO Box 417005
Kansas City, MO 64141-7005
We will acknowledge receipt of your Grievance within 10 working days and conduct a thorough review. We will respond to your Grievance within 20 working days. If we are not able to respond to your post-service Grievance within 20 working days we will notify you of the time frame extension but the entire time will not exceed the time frame required by your plan or 60 calendar days, whichever is less (pre-service Grievances will be handled within 20 working days).
Procedures for Filing a Second Level Grievance
If our response to your Grievance does not satisfy all your concerns, you may have the right to file a Second Level Grievance. Please refer to the Grievance letter for additional appeal rights. Not all contracts offer the option for a Second Level Grievance. We will acknowledge receipt of your communication within 10 working days, and review (with the assistance of a Grievance Advisory Panel) the results of our previous review, as well as any new information provided to us at the time of your latest request.
Our Grievance Advisory Panel consists of other enrollees and appropriate representatives of management that were ot involved in the circumstances giving rise to the Grievance or in any susequent investigation or determination of the Grievance.
If the Grievance involves an Adverse Determination, the panel will consist of a majority of persons that are appropriate clinical peers in the same or similar specialty as would manage the case being reviewed who were not involved in the circumstances giving rise to the Grievance or in any subsequent investigation or determination of the Grievance.
The Panel will convene within 20 working days of the date of receipt of the Second Level Grievance, or we will notify you of the time extension. The entire time will not exceed the time frame required by your plan or 60 calendar days, whichever is less for post-service Grievances, (pre-service Grievances will be handled within 20 working days). You will be advised of the decision of the Grievance Advisory Panel within 5 working days of the Panel's determination.
Contact the State Department of Insurance
You may, at any time, contact the Kansas or Missouri Department of Insurance, whichever is appropriate. You may also have the right to have your Grievance reviewed by an Independent Review Organization (IRO) at no cost to you.
Missouri Department of Insurance
PO Box 690
Jefferson City, MO 65102-7390
Phone: 1-800-726-7390Kansas Department of Insurance
420 SW 9th Street
Topeka, KS 66612-1678
Phone: 1-800-432-2484
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.
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.
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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