Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 6 contracts
Sources: Medicare Supplement Plan A, Medicare Supplement Plan C, Medicare Supplement Plan A
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers Sub- scribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- sion as described above or involves a determina- tion that the requested service is experimental/investigational, you may immedi- ately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Cus- tomer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 5 contracts
Sources: Evidence of Coverage and Health Service Agreement, Medicare Supplement Plan G, Evidence of Coverage and Health Service Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 4 contracts
Sources: Medicare Supplement High Deductible Plan F Evidence of Coverage and Health Service Agreement, Medicare Supplement Plan K Evidence of Coverage and Health Service Agreement, Medicare Supplement Plan F
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 3 contracts
Sources: Medicare Supplement Plan a Evidence of Coverage and Health Service Agreement, Medicare Supplement Plan F Extra, Medicare Supplement Plan A
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 2 contracts
Sources: Medicare Supplement Plan G, Medicare Supplement Plan N
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 2 contracts
Sources: Medicare Supplement Plan G Extra, Medicare Supplement Plan C
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 daysdays. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. See the previous Customer Service section If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 2 contracts
Sources: Medicare Supplement Plan K, Medicare Supplement Plan N
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 2 contracts
Sources: Medicare Supplement Plan F Extra, Medicare Supplement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- sion as described above or involves a determina- tion that the requested service is experimental/investigational, you may immedi- ately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Cus- tomer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 2 contracts
Sources: Medicare Supplement Plan F, Medicare Supplement Plan F
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711number,711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance griev- ance system allows Subscribers to file grievances for at least 180 days following any incident or action ac- tion that is the subject of the Subscriber’s dissatisfac- tiondissatis- faction. Grievances are normally resolved within 30 days. See the previous Customer Service section sec- tion for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇P.O. Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance griev- ance system allows Subscribers to file grievances for at least 180 days following any incident or action ac- tion that is the subject of the Subscriber’s dissatisfac- tiondissatis- faction. Grievances are normally resolved within 30 days. See the previous Customer Service section sec- tion for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experi- mental/investigational, you may immediately re- quest an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Cus- tomer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the ex- ternal review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the ser- vice is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external re- view process is in addition to any other proce- dures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the ex- ternal review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan C
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan G Extra
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan K
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance griev- ance system allows Subscribers to file grievances for at least 180 days following any incident or action ac- tion that is the subject of the Subscriber’s dissatisfac- tiondissatis- faction. Grievances are normally resolved within 30 days. See the previous Customer Service section sec- tion for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Servicesservices, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Identifica- tion Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decisiondeci- sion. The Subscriber, physician, or representative of the Subscriber may request an expedited decision deci- sion when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing experienc- ing severe pain. Blue Shield shall make a decision deci- sion and notify the Subscriber and physician within 72 hours following the receipt of the requestre- quest. An ex- pedited expedited decision may involve admissionsad- missions, contin- ued stay continued stay, or other healthcare Serviceshealth care Ser- vices. If you would like additional information regarding re- ▇▇▇▇▇▇▇ the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisionex- pedited decision, please contact our Customer Service De- partmentSer- vice Department. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letterlet- ter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number as noted in this Agreement. If the telephone inquiry to Customer Service does not resolve re- solve the question or issue to the Subscriber's satisfactionsatis- faction, the Subscriber may request a grievance at that time, which the Customer Service Representative Representa- tive will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident inci- dent or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or services for which coverage was denied by Blue Shield in whole or in part on the grounds that the ser- vice is not medically necessary or is experi- mental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normal- ly must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the re- quested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be ob- tained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determi- nation of whether the care is medically neces- sary. You may choose to submit additional records to the external review agency for re- view. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request exter- nal review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. P.O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request exter- nal review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested ser- vice is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by con- tacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to sub- mit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external re- view agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in ad- dition to any other procedures or remedies availa- ble to you and is completely voluntary on your part; you are not obligated to request external re- view. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has you have experienced, you may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s ’ toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe painSubscriber. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances grievance to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number as noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance Grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. The following Independent Medical Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Service Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section External Independent Medical Review NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan N
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- ▇▇▇▇ as described above or involves a determina- tion that the requested service is experimental/in- vestigational, you may immediately request an external review following receipt of notice of ▇▇- ▇▇▇▇. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan G
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these the- se matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process., or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan G
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Cardcard. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Ex- perimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request exter- nal review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested ser- vice is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by con- tacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to sub- mit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external re- view agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in ad- dition to any other procedures or remedies availa- ble to you and is completely voluntary on your part; you are not obligated to request external re- view. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about ServicesSer- vices, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access ac- cess to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Identi- fication Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 7111-800- 241-1823. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decisionde- cision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision deci- sion when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing experi- encing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician physi- cian within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued stay continued stay, or other healthcare health care Services. If you would like additional information infor- mation regarding the expedited decision processpro- cess, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact con- tact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review re- view committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee re- view committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review re- view of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted as not- ed in this Agreement. If the telephone inquiry in- quiry to Customer Service does not resolve the question or issue to the Subscriber's satisfactionsat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". ." The Subscriber may request this Form from Customer Cus- tomer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following follow- ing any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances Griev- ances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan A
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- sion as described above or involves a determina- tion that the requested service is experimental/investigational, you may immedi- ately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Cus- tomer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these the- se matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711number,711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan D
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has you have experienced, you may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe painSubscriber. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number as noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five - (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Agreement
Customer Service. A Subscriber who has a question about Servicesservices, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Identifica- tion Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711number,711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decisiondeci- sion. The Subscriber, physician, or representative of the Subscriber may request an expedited decision deci- sion when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing experienc- ing severe pain. Blue Shield shall make a decision deci- sion and notify the Subscriber and physician within 72 hours following the receipt of the requestre- quest. An ex- pedited expedited decision may involve admissionsad- missions, contin- ued stay continued stay, or other healthcare health care Services. If you would like additional information infor- mation regarding the expedited decision process, or if you believe your particular situation qualifies quali- fies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letterlet- ter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number as noted in this Agreement. If the telephone inquiry to Customer Service does not resolve re- solve the question or issue to the Subscriber's satisfactionsatis- faction, the Subscriber may request a grievance at that time, which the Customer Service Representative Representa- tive will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident inci- dent or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or services for which coverage was denied by Blue Shield in whole or in part on the grounds that the ser- vice is not medically necessary or is experi- mental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normal- ly must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the re- quested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be ob- tained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determi- nation of whether the care is medically neces- sary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is bind- ing on Blue Shield; if the external reviewer de- termines that the service is medically necessary, Blue Shield will promptly arrange for the ser- vice to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external re- view may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Cardcard. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711number,711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request exter- nal review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested ser- vice is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by con- tacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to sub- mit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will re- ceive copies of the opinions of the external review agency. The decision of the external review agen- cy is binding on Blue Shield; if the external re- viewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in ad- dition to any other procedures or remedies availa- ble to you and is completely voluntary on your part; you are not obligated to request external re- view. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, Services providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711number,711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondeci- sion, please contact our Customer Service De- partmentDepart- ment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. P.O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Agreement
Customer Service. A Subscriber who has a question about Services, Services providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondeci- sion, please contact our Customer Service De- partmentDepart- ment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. P.O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇Bo▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- sion as described above or involves a determina- tion that the requested service is experimental/investigational, you may immedi- ately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Cus- tomer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan K
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe se- vere pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty societyso- ciety, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination de- termination concerning a claim or Service. Sub- scribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investi- gational (including the external review available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treat- ment Act of 1996), you may choose to make a re- quest to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with Cal- ifornia law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited deci- sion as described above or involves a determina- tion that the requested service is experimental/in- vestigational, you may immediately request an external review following receipt of notice of ▇▇- ▇▇▇▇. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will re- view the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qual- ified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the exter- nal review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan F Extra
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay stay, or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone tel- ephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tion. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process.
Appears in 1 contract
Sources: Medicare Supplement Plan
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider pro- vider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact con- tact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service Ser- vice does not resolve the question or issue to the Subscriber's Sub- ▇▇▇▇▇▇▇'▇ satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider pro- vider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information in- formation on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request exter- nal review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested ser- vice is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by con- tacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to sub- mit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will re- ceive copies of the opinions of the external review agency. The decision of the external review agen- cy is binding on Blue Shield; if the external re- viewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in ad- dition to any other procedures or remedies availa- ble to you and is completely voluntary on your part; you are not obligated to request external re- view. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan D
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. NOTE: The following Independent Medical Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has you have experienced, you may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s ’ toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe painSubscriber. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances grievance to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number as noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇Box 5588, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇El Dorado Hills, ▇▇ ▇▇▇▇▇CA 95762-▇▇▇▇0011. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance Grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section for information on the expedited decision process. The following Independent Medical Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Health Service Agreement
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns concerns regarding the quality of care or access to care that he has experienced, may call Blue Shield’s Customer Service Department at the tel- ephone telephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇Subscriber, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited expedited decision may involve admissions, contin- ued continued stay or other healthcare Services. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cisiondecision, please contact our Customer Service De- partmentDepartment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia California Medical Association or a medical specialty society, or other appropriate peer review commit- tee committee for an opinion to assist in the resolution of these matters. matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate initiate a grievance by submitting a letter or a com- pleted completed "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance grievance within five (5) calendar days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber’s dissatisfac- tiondissatisfaction. Grievances are normally resolved within 30 days. See the previous Customer Service section NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for information which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experimental/investigational (including the external review available under the ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submitted to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested service is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in addition to any other procedures or remedies available to you and is completely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information regarding the external review process, or to request an application form, please contact Customer Service.
Appears in 1 contract
Sources: Medicare Supplement Plan F Extra
Customer Service. A Subscriber who has a question about Services, providers, benefits, how to use this plan, or con- cerns regarding the quality of care or access to care that he has experienced, may call Blue Shield▇▇▇▇▇▇’s Customer Service Department at the tel- ephone number indicated on your Identification Card. The hearing impaired may contact Blue Shield’s Customer Service Department through Blue Shield’s toll-free TTY number, 711▇-▇▇▇-▇▇▇-▇▇▇▇. Customer Service can answer many questions over the telephone. Note: Blue Shield has established a procedure for our Subscribers to request an expedited decision. The Subscriber, physician, or representative of the Subscriber may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Sub- ▇▇▇▇▇▇▇, or when the Subscriber is experiencing severe pain. Blue Shield shall make a decision and notify the Subscriber and physician within 72 hours following the receipt of the request. An ex- pedited decision may involve admissions, contin- ued stay or other healthcare Servicesservices. If you would like additional information regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited de- cision, please contact our Customer Service De- partment. Blue Shield may refer inquiries or grievances to a local medical society, hospital utilization review committee, peer review committee of the Califor- nia Medical Association or a medical specialty society, or other appropriate peer review commit- tee for an opinion to assist in the resolution of these matters. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Sub- scribers Subscribers may contact Blue Shield at the telephone tele- phone number noted in this Agreement. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance griev- ance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also ini- tiate a grievance by submitting a letter or a com- pleted "Grievance Form". The Subscriber may request this Form from Customer Service. The completed form should be submitted to Customer Service Appeals and Grievance, P. O. ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. The Subscriber may also submit the grievance online by visiting our web site at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Blue Shield will acknowledge receipt of a griev- ance within five - (5) calendar days. The grievance griev- ance system allows Subscribers to file grievances for at least 180 days following any incident or action ac- tion that is the subject of the Subscriber’s dissatisfac- tiondissatis- faction. Grievances are normally resolved within 30 days. See the previous Customer Service section sec- tion for information on the expedited decision process. NOTE: The following Independent Medical Re- view process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. If your grievance involves a claim or Services for which coverage was denied by Blue Shield in whole or in part on the grounds that the service is not medically necessary or is experi- mental/investigational (including the external re- view available under the ▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇ Experimental Treatment Act of 1996), you may choose to make a request to the Department of Managed Health Care to have the matter submit- ▇▇▇ to an independent agency for external review in accordance with California law. You normally must first submit a grievance to Blue Shield and wait for at least 30 days before you request exter- nal review; however, if your matter would qualify for an expedited decision as described above or involves a determination that the requested ser- vice is experimental/investigational, you may immediately request an external review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by con- tacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is medically necessary. You may choose to sub- mit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external re- view agency. The decision of the external review agency is binding on Blue Shield; if the external reviewer determines that the service is medically necessary, Blue Shield will promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in ad- dition to any other procedures or remedies availa- ble to you and is completely voluntary on your part; you are not obligated to request external re- view. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more infor- mation regarding the external review process, or to request an application form, please contact Customer Service.
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Sources: Medicare Supplement Plan