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Coverage decisions
When we make an organization determination, we are making a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called "coverage decisions" in your Evidence of Coverage (EOC).
Certain services need prior approval for payment by the plan. Your EOC provides an explanation of what services require prior approval.
Prior approval means we review the information before the service occurs. Information needed for these reviews includes the name of your ordering physician, the name of the provider of service, the type of service(s) needed, and any supporting medical information.
You or your physician may contact the Plan by phone, mail, or in-person to request prior approval for a service. You may also appoint an individual to act as your representative in filing a request for prior approval. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a request for prior approval for you.
A request by your representative is not valid until the Appointment of Representative (AOR) form (PDF), or other equivalent form, legal papers, or authority is submitted to the Plan.
By phone:
Blue Medicare HMO℠
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO℠
877-494-7647 (TTY 888-451-9957 / 711)
7 days a week, 8 AM to 8 PM
By mail:
Blue Cross and Blue Shield of North Carolina
Attn: Care Management
P.O. Box 1291
Durham, NC 27702-1291
The prior approval review will be made as quickly as possible once all of the necessary medical information is received. You will receive a written response when a decision is made.
- The time frame for a standard request is no more than 14 calendar days.
- The time frame for an expedited request is 72 hours.
- We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information, and the delay is in your best interest.
Standard appeals
You can appeal a denied Notice of Denial of Medical Coverage decision, Notice of Denial of Payment decision, or if you are disputing a Copayment or Coinsurance amount you are being billed for, by sending a written, signed request detailing why you think the denial should be overturned. If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you. An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal. Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.
An appeal must be filed within 60 calendar days of the denial notice that we sent to you.
You may file your appeal by:
Mail:
Blue Cross and Blue Shield of North Carolina
Attn: Medicare Appeals and Grievances Department
P.O. Box 1291
Durham, NC 27702-1291
Fax:
888-375-8836
We will investigate your concern(s) and respond to you in writing. Our response to a standard appeal of a Notice of Denial of Medical Coverage will be sent within 30 calendar days of the Plan's receipt of the appeal, or within 44 calendar days if an extension was taken. Our response to an appeal of a Notice of Denial of Payment will be sent within 60 calendar days of the Plan's receipt of the appeal.
Expedited or fast appeals
If you or your doctor believes that waiting on a standard appeal decision on a Notice of Denial of Medical Coverage could seriously harm your health or your ability to function, you, your authorized representative, or your doctor can ask for an expedited or fast appeal. Note: An appeal request for a Notice of Denial of Payment or Copayment or Coinsurance dispute cannot be expedited.
To file an expedited or fast appeal:
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
7 days a week, 8 AM to 8 PM
If calling after business hours, just follow the prompts to file an expedited or fast appeal.
By mail:
Blue Cross and Blue Shield of North Carolina
Attn: Medicare Appeal and Grievance Department
P.O. Box 1291
Durham, NC 27702-1291
By fax:
888-375-8836
We will respond by phone and in writing to an expedited appeal within 72 hours of our receipt of the expedited or fast appeal request. If someone other than you or your physician decides to file an expedited or fast appeal for you, an Appointment of Representative (AOR) form (PDF) must be received before the appeal review can begin.
We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
If you receive an Important Message from Medicare About Your Rights for your inpatient hospital services from the provider and you want your inpatient hospital services to be covered longer, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO. Please follow the instructions contained in the Important Message for the steps to follow to file an appeal with the BFCC-QIO.
If you receive an advance Notice of Medicare Non-Coverage for skilled nursing, home health, or comprehensive outpatient rehabilitation services from the provider of the service, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO, regarding the upcoming termination of services. Please follow the instructions contained in the Notice for the steps to follow to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization.
Please see your Evidence of Coverage for a detailed explanation of the appeals and grievance procedures and time frames for a response. Refer to the Evidence of Coverage for your plan.
To obtain an aggregate number of Medicare Advantage Plan appeals and quality of care grievances, you may call Customer Service at 888-310-4110 (toll-free) for Blue Medicare HMO or 877-494-7647 for Blue Medicare PPO, 888-451-9957 / (TTY 711), 7 days a week, 8 AM to 8 PM ET.
Appeals
For a detailed explanation of the appeals and grievance procedures and time frames for a response, refer to the Evidence of Coverage for your plan.
To obtain an aggregate number of Medicare Advantage Plan appeals and quality of care grievances, you may call Customer Service at 888-310-4110 (toll-free) for Blue Medicare HMO or 877-494-7647 for Blue Medicare PPO, 888-451-9957 / TTY: 711, 7 days a week, 8 AM to 8 PM ET.
An appeal is your opportunity to request a redetermination of an adverse coverage determination.
Standard appeals
You can appeal a Notice of Denial of Medical Coverage decision or a Denial of Payment decision, or you can dispute the Copayment or Coinsurance amount you are being billed. Appeal requests for a Denial of Payment decision must be submitted in writing and include why you think the denial should be overturned. You may also appeal a Denial of Medical Coverage by calling Blue Cross and Blue Shield of North Carolina.
You or your provider may file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you. An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal. Your provider can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
7 days a week, 8 AM to 8 PM ET
Mail:
Blue Cross and Blue Shield of North Carolina
Attn: Medicare Provider Appeal Department
P.O. Box 1291
Durham, NC 27702-1291
Fax:
888-375-8836
We will investigate your concern(s) and respond to you in writing. Our response to a standard appeal of a Notice of Denial of Medical Coverage will be sent within 30 calendar days of the Plan's receipt of the appeal, or within 44 calendar days if an extension was taken. Our response to an appeal of a Notice of Denial of Payment will be sent within 60 calendar days of the Plan's receipt of the appeal.
Expedited or fast appeals
If you or your doctor believes that waiting on a standard appeal decision on a Notice of Denial of Medical Coverage could seriously harm your health or your ability to function, you, your authorized representative, or your doctor can ask for an expedited or fast appeal.
Note: An appeal request for a Notice of Denial of Payment or Copayment or Coinsurance dispute cannot be expedited.
You or your doctor can request an expedited or fast appeal.
If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you. An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal. Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
7 days a week, 8 AM to 8 PM ET
If calling after business hours, just follow the prompts to file an expedited or fast appeal.
By mail:
Blue Cross and Blue Shield of North Carolina
Attn: Medicare Provider Appeal Department
P.O. Box 1291
Durham, NC 27702-1291
By fax:
888-375-8836
We will respond by phone and in writing to an expedited appeal within 72 hours of our receipt of the expedited or fast appeal request. If someone other than you or your physician decides to file an expedited or fast appeal for you, an Appointment of Representative (AOR) form (PDF) must be received before the appeal review can begin.
We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
If you receive an Important Message from Medicare About Your Rights for your inpatient hospital services from the provider and you want your inpatient hospital services to be covered longer, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO. Please follow the instructions contained in the Important Message for the steps to follow to file an appeal with the BFCC-QIO.
If you receive an advance Notice of Medicare Non-Coverage for skilled nursing, home health, or comprehensive outpatient rehabilitation services from the provider of the service, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO, regarding the upcoming termination of services. Please follow the instructions contained in the Notice for the steps to follow to file an appeal with the BFCC-QIO.
Grievances
A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.
Please see your Evidence of Coverage for a detailed explanation of the grievance procedures and time frames for a response.
The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance.
A Medicare beneficiary may appoint an individual to act as his / her representative in filing a grievance. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a grievance. A grievance by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers, or authority are submitted.
You or your appointed representative may file a grievance by phone, mail, fax, or in-person. You can also file a complaint with Medicare.
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
7 days a week, 8 AM to 8 PM ET
By mail:
Blue Cross and Blue Shield of North Carolina
Attn: Medicare Provider Appeal Department
P.O. Box 1291
Durham, NC 27702-1291
By fax:
888-375-8836
Via Acentra Health
If you are dissatisfied with the quality of care you have received, you may also file your grievance with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina is Acentra Health.
By phone:
888-317-0751 or for the hearing and speech impaired call 855-843-4776 (TTY / TDD)
By mail:
5201 W. Kennedy Blvd.
Suite 900
Tampa, FL 33609
By fax:
844-878-7921
Online: www.acentraqio.com
The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after we receive the grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after we receive the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.
If we have denied your request for an expedited coverage decision or an expedited appeal, or if we have taken a 14-calendar-day extension on the time frame for a coverage decision or appeal and you disagree with those actions, you may file an expedited or fast grievance. Our response will be provided within 24 hours after we receive the grievance.
Disclosures:
Blue Cross and Blue Shield of North Carolina is an HMO, HMO-POS, PPO and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of North Carolina is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
Blue Medicare Supplement plans offered: Plan A: BMS A, 1/24, Plan G: BMS G, 1/24, Plan HI DED G: BMS HDG, 1/24, Plan K: BMS K, 1/24, Plan N: BMS N, 1/24.
Blue Medicare Supplement is not endorsed by or affiliated with the United States Government or the federal Medicare program.
The federal government requires all Medicare Advantage members to continue paying their Part B premium each month.
Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, sexual orientation or source of payment. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.
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Current as of 07/12/2024 | Y0079_12997_M CMS Accepted 10202024 | U36079, 6/24
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