Navigate Your Medical Care: Appeals and Grievances

If coverage for an item or medical care is denied and you think it should be covered, you can file an appeal.

• You will get a written response to your appeal as quickly as your case requires. The response will be:
  • No later than 30 calendar days after we receive your appeal for medical service authorization.
  • No later than 60 calendar days after we receive your appeal for payment.
• We may add to the time frame by up to 14 calendar days if you ask for an extension.

You may request a medical appeal by fax or mail. Visite nuestro Comuníquese con nosotros para encontrar más información.

• Puede solicitar una apelación acelerada (rápida) si:
  • Coverage was denied and your health requires a quick response.
  • You think that your covered care in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility is ending too soon.
• You will get a written response to your expedited appeal as quickly as your case requires based on your health status. This will be no later than 72 hours after we receive your expedited appeal.
• We may extend the time frame by up to 14 calendar days if you ask for an extension.
• If there's a need for more information and the delay is in your best interest, the appeal can take longer. When we extend the deadline, we will let you know right away the reason(s) for the delay in writing.

You may request an expedited medical appeal by phone or fax. Visite nuestro Comuníquese con nosotros para encontrar más información.

You can file a grievance if you have a complaint about:

• The quality of care you receive.
• The timeliness of service.
• Any other concern (except for the coverage or payment issues listed above).

Si tiene un problema relacionado con lo que cubre los servicios médicos, o si usted o su representante designado desean presentar una queja, llámenos. Visite nuestra página Comuníquese con nosotros página. También puede presentar una queja por fax o correo.

Important: You must file a grievance with us no later than 60 days after the event or incident in question.

You may also contact Customer Service if you want to know about the number of appeals, grievances or exceptions filed with the plan.

Here are examples of reasons you may file a grievance:

• Siente que lo incitamos a renunciar (cancelar la cobertura) a nuestra cobertura.
• Concerns with customer service.
• Long wait times for a pharmacy or medical office.
• Disrespectful or rude behavior by pharmacists or medical staff.
• Cleanliness or condition of a pharmacy or medical office.
• You do not agree with our decision not to expedite your request for an expedited coverage determination or redetermination.
• Considera que nuestros avisos y demás material escrito son difíciles de entender.
• El patrocinador de la cobertura (BCBSTX) no le dio una decisión dentro del plazo requerido.
• BCBSTX no remitió su caso de apelación para una revisión independiente si no le dimos una decisión dentro del plazo requerido.
• We did not provide required notices, and/or the notices did not comply with Centers for Medicare & Medicaid Services (CMS) standards.

Resolución de problemas

A grievance must be filed with us no later than 60 days after the event or incident in question.

Resolve by Phone
Intentamos resolver cualquier queja que tenga por teléfono. Si Servicio al Cliente no puede resolver su problema por teléfono, disponemos de un proceso formal para revisar sus quejas. Este proceso es muy sencillo, por lo que obtendrá una respuesta rápida.

• Si su problema no se resuelve la primera vez que llama, se lo remitirá a un coordinador de inconformidades para que lo resuelva.
• Si su inconformidad tiene que ver con la calidad de la atención médica que recibió, recibirá una respuesta por escrito.
• You will be sent a written response as quickly as your case requires based on your health status. This will be no later than 30 calendar days after we receive your complaint.
• We may add to the time frame by up to 14 calendar days if you request an extension.
• If there's a need for more information and the delay is in your best interest, the reply can take longer. When we extend the deadline, we will let you know right away the reason(s) for the delay in writing.

Por correo
Puede presentar una inconformidad por escrito enviando una carta por correo o por fax informándonos sobre ella.

Usted puede elegir a alguien que actúe en su nombre. This is called “an appointment of representative.”

• Esta persona puede ser un pariente, amigo, patrocinador, abogado o médico.
• Un tribunal también puede nombrar a alguien.
• Usted y la persona que elija deben completar, fechar y firmar una declaración representativa.
• The notice or request may also be made in a written letter. Si usted no está legalmente en su sano juicio o está incapacitado, el representante puede completar y firmar la declaración.
• El representante debe tener los documentos legales correctos o la autoridad legal para firmar por usted.
• Si usted elige a un abogado, solo usted deberá firmar la declaración de representatividad.
• La declaración de representatividad debe incluir su nombre y el número de reclamación de Medicare.

Forms you can use:

• Formulario de Nombramiento de Representante de CMS 
  
• Formulario de administración del Seguro Social

What if you need a drug that isn't covered? There are things you can do to request an exception. Find out how coverage decisions are made. Visite Drug Coverage Determinations, Appeals and Grievances.