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Provider and Facility Reference Manual

Section 15 - Member Information

Member Rights and Responsibilities

As partners in health care, each of us has rights and responsibilities that we must follow in order to make the most of our members' health benefits. The following rights and responsibilities apply to our members:

Member Rights

Members have the right to:

  • Receive information about the health plan, its services, its practitioners and providers, and member rights and responsibilities
  • Treatment with respect, consideration, dignity and privacy
  • Information about all services available through the health plan, including how to obtain emergency and after-hours care
  • Confidentiality of their medical records
  • Candid discussions concerning appropriate or medically necessary treatment options for their condition(s), regardless of cost or benefit coverage
  • Voice complaints or appeals about the health plan or the care provided
  • Request to see the physician selected for their primary care services instead of another member of his/her office staff for an office visit, if they are willing to wait for an available appointment
  • Make recommendations regarding the health plan's member right and responsibilities policies


Patient Rights

As a patient, our members have a right to expect the following from their physicians or other providers:

  • To participate in decisions concerning their health care
  • To refuse treatment to the extent permitted by law, and to be informed of the medical consequences of that action
  • To obtain from their physician or other health care provider complete and current information concerning a diagnosis, treatment, or prognosis, in terms they can reasonably be expected to understand; when it is not advisable to give such information to a member, the information shall be made available to an appropriate person on their behalf
  • To receive information from their physician or other provider necessary to give informed consent prior to the start of any procedure
  • To know the name and qualifications of all their caregivers; information can be obtained from the provider or the administrator of any health care facility
  • If a member feels that their physician has not given them the kind of service they have the right to expect, our members have the right to follow the complaint procedure for Quality of Care Access Review; they can refer to their member handbook or contact customer service


Member Responsibilities
 

  • Establish themselves as a patient of the physician they have selected for their primary care services
  • Follow the instructions and guidance of health care providers
  • Provide honest and accurate information concerning their health history and status
  • Participate in understanding their health problems and developing mutually agreed upon treatment goals
  • Follow carefully the health plan's policies and procedures as described in their member handbook and their contract(s) and rider(s)
  • Be sure that their primary care physician coordinates any health care they receive in order to receive the highest level of benefits, if applicable under the terms of your plan coverage
  • Carry their member ID card with them and present it when seeking health services
  • Advise their health plan of any changes that affect them or their family such as birth, change of address, or marriage
  • Submit all bills they receive from a non-participating provider within one year from the date of service
  • Notify their health plan when anyone included in their coverage becomes eligible for Medicare or any other group health insurance
  • Keep their health plan informed of their concerns about the medical care they receive
  • Pay appropriate copayments/deductible/coinsurance or other patient responsibility to providers when services or supplies are received

Grievance and Appeal

If a member encounters any concerns, they can usually be resolved with a call to the Member Services Department.

Unresolved complaints or requests to change contractual determinations that are not in regard to medical necessity determinations or experimental/investigational determinations can be reviewed through the grievance and appeal procedures.  Adverse medical necessity determinations or experimental/investigational determinations are reviewed through the Utilization Management appeals process.

Our grievance and appeal procedure is designed to ensure a timely review of:

  • Our members concerns regarding our policies and procedures; or
  • Any decision that we have made regarding a service that they believe is covered by Blue Cross Blue Shield, or should be provided to them as part of their coverage.

A grievance can be requested for any determination made by Blue Cross Blue Shield other than a decision that a service is not medically necessary or is experimental or investigational in nature. Examples of concerns that may be reviewed under our grievance and appeal procedure include, but are not limited to, the following:

  • denial of a referral to a specialist,
  • denial of coverage for a referred service,
  • denial because a benefit is not covered according to the terms of the member's contract(s),
  • denial of a benefit because it was provided by an ineligible provider or at an ineligible place of service, and
  • a determination that they were not a member of Blue Cross Blue Shield at the time services were rendered.

Traditional Indemnity members, including PPO/EPO, and for individual market products sold on or off the exchanges have a one level grievance process with the following timeframes for response:

  • Urgent cases: 72 hours
  • Pre-service: 30 calendar days
  • Post-service: 60 calendar days

There is a two level grievance and appeal process for HMO and POS members, and for small group products sold on or off the exchanges described below.

As always, you may file a grievance at your discretion. Blue Cross Blue Shield will not take any discriminatory action against you because you have filed a grievance or an appeal.

Designating a Representative

Members may designate someone to represent them with regard to their grievance or appeal at any level. If a representative is designated, we will communicate with the member and their representative, unless directed otherwise. In order to appoint a representative, the member must complete, sign, and return the Appointment of Authorized Representative Form. This form can be requested by calling Member Services at 1-800-544-2583.

In cases involving urgent care, a health care professional with knowledge of their medical condition may act as their authorized representative without the need to complete the Appointment of Authorized Representative Form.

Initiating a Grievance (Level I)

Any time Blue Cross Blue Shield denies a referral or determines that a benefit is not covered under the member's contract(s), the member will receive notification of our grievance procedures. A written or oral grievance may be filed up to 180 days after the receipt our original determination. Requests for a grievance should state the name and identification number of the member for whom the benefit or referral was denied. It should also describe the facts and circumstances relating to the case. Oral or written comments, documents, records, or other information relevant to the grievance may be submitted.

A grievance may be initiated by calling our Member Service Department at 1-800-544-2583. Our Member Services Department hours are 8 a.m. - 7 p.m., Monday through Friday. When our offices are closed, the member may notify us about the grievance by leaving a detailed message with our answering service. We will acknowledge receipt of the oral grievance by telephone within one business day of receipt of the message. You may contact Customer Service for language assistance free of charge or if you have special needs.

Please send all written requests for a grievance to:

Grievance Department
Highmark Blue Cross Blue Shield of Western New York
PO Box 15068
Albany, NY 12212

We will send a written acknowledgment of receipt of a member's grievance within 15 calendar days. This letter will include the name, address and telephone number of the department that is handling the grievance. It may be necessary to ask for additional information before we can review the grievance. If this is necessary, we will contact the member.

A Member Services Representative who was not involved in the initial determination and who is not a subordinate of the initial reviewer, will thoroughly research the case by contacting all appropriate departments and providers. The Member Service Representative will review all relevant documents, records, and other information including any written comments, documents, records and other information the member or their representative have submitted.

If the issues involved are of a clinical nature, it will be reviewed by a health care provider who was not involved in our initial determination and who has appropriate training and experience in the field of medicine involved in the medical judgment. Clinical matters would be those that require appropriate medical knowledge and experience in order to make an informed decision. The member will be contacted within the following time frames:

In urgent cases, when a delay would significantly increase the risk to the member's health, a decision will be made and communicated to the member by telephone within 48 hours after receipt of the grievance. The member will also be contacted in writing within two business days of the notice by telephone.

In cases involving requests for referrals or disputes involving contract benefits and all other non-urgent cases, a decision will be made and communicated to the member as follows:

  • Pre-Service Claims: In writing within 15 calendar days after receipt of the grievance.
  • Post-Service Claims: In writing within 30 calendar days after receipt of the grievance.

Our response to our member will include the detailed reasons for our determination, the provisions of the contract, policy or plan on which the decision was based, a description of any additional information necessary for the member to perfect their claim, and why the information is necessary, the clinical rationale in cases requiring a clinical determination, the process to file an appeal and an appeal form.

Appealing an Upheld Denial (Level II)

If a member remains dissatisfied with the outcome of their grievance, they may file an appeal. A request for an appeal should include any additional information the member feels is necessary. Members have 60 business days from the time they receive the grievance determination to submit an appeal to Blue Cross Blue Shield. They may submit their request for an urgent appeal verbally or in writing. For a non-urgent appeal, they may submit a written request in the form of a letter or use our appeal form. The member will receive a copy of our appeal form with the original grievance decision. They may submit any written comments, documents, records or other additional information with their appeal.

We will send written acknowledgment of our receipt of the appeal request within 15 calendar days. This notice will include the name, address and telephone number of the individual who will respond to the member's appeal.

Non-clinical matters will be reviewed by a panel comprised of representative staff from our Network Services, Member Services, Quality Management and Utilization Management areas who were not previously involved in your grievance.

If the appeal involves a clinical matter, it will be reviewed by a panel of personnel qualified to review clinical matters. This includes licensed, certified, or registered health care professionals `who did not make the initial determination. At least one of the health care professionals reviewing the appeal will be a Clinical Peer Reviewer. (A Clinical Peer Reviewer is a licensed physician or a licensed, certified, or registered health care professional that has appropriate training and experience in the field of medicine involved in the medical judgment.)

We will make a decision regarding the appeal and send the member notification within the following periods:

  • In urgent cases, a decision will be made and notice provided by telephone within 24 hours after receipt of the Level II grievance appeal followed by written notice within two business days after receipt of the appeal.
  • For non-urgent pre-service claims, a written decision will be sent within 15 calendar days from receipt of the appeal.
  • For post-service claims, a written decision will be provided within 30 calendar days from receipt of the appeal.

Our notification to the member with regard to their appeal will include the detailed reasons for our determination, the provisions of the contract, policy, or plan on which the decision was based, and the clinical rationale in cases where the determination has a clinical basis.

Member Grievance/Appeal

Upon written request, and free of charge, our members have the right to have access to copies of all documents, records, and other information relevant to their claim and details regarding diagnosis/treatment. Members also have the right to request, in writing, the name of each medical or vocational expert whose advice was obtained in connection with their claim.

Upon written request, and free of charge, members have the right to an explanation of any scientific or clinical judgment for the determination to deny their claim that applies the terms of their contract, policy or plan to your medical circumstances.

Upon written request, and free of charge, members have the right to a copy of each rule, guideline, protocol or similar criteria that was relied upon in making the determination to deny their claim.

Members have a right to file a complaint at any time with the New York State Department of Health at 1-800-206-8125 or the NYS Department of Financial Services Consumer Service Bureau at 1-800-342-3736.

For questions about your appeal rights or assistance you can contact the Employer Benefits Security Administration at 1-866-444-3272 or Community Service Society of New York, Community Health Advocates at 1-888-614-5400.

Members may have the right to bring a civil action under the Employment Retirement Income Security Act of 1974 (ERISA) §502 (a) if they file an appeal and their request for coverage or benefits is denied following review. Members have this right if their coverage is provided under a group health plan that is subject to ERISA.

Quality of Care Access Review

As a Blue Cross Blue Shield member, members have the right to ask us to look into their concern about quality of care or timely access to a provider. We closely track all complaints. If we receive similar complaints from our customers about a provider during a certain time period, we address those issues with the provider. This is our informal process.

We also have a formal process. At a member's request, we will investigate their concern by requesting records or other documentation. Our Medical Director reviews this information. If necessary, our Medical Director will meet with the provider to discuss the concern.

If a member has a concern or problem regarding their ability to see a Blue Cross Blue Shield provider in a timely fashion or the quality of care they receive, they can contact our Member Services Department at 1-800-544-2583.

We will send the member a letter that explains the complaint process and gives them a number to call if they wish to file a formal complaint. It also explains the appeal process if the member disagrees with the way our staff handles their concerns.

Unresolved Disputes

We always recommend that members follow our grievance or utilization review process to remedy any issues concerning their coverage. However, if they are not satisfied with any Blue Cross Blue Shield decision, members have the right to contact the New York State Department of Financial Services or the New York State Department of Health (DOH). The addresses and telephone numbers for these agencies are:

New York State Department of Health
Corning Tower
Albany, NY 12237
1-800-206-8125

New York State Department of Financial Services
One Commerce Plaza
Albany, NY 12257
1-800-342-3736

Additional Member Resources


health navigator

(844) 639-2435
A personal health care coaching and patient advocacy service members can call anytime they need help navigating the health care system

Behavioral Health Assistance

1-877-837-0814
For assistance in obtaining mental health and substance abuse treatment

Fraud and Abuse Hotline

1-800-333-8451
reportfraud@bcbswny.com

Express Scripts®

(866) 264-4685
For questions on pharmacy benefits