Member Grievance Process
Rev 9-23-10
If your complaint is not subject to resolution through the Appeal Process, you may submit a member grievance to BCBSAZ.
You must send BCBSAZ your grievance request within one (1) year of the notice of the adverse benefit determination, or date of
occurrence if not related to a benefit determination. BCBSAZ has discretion to extend this time limit for good cause. Examples
of good cause include a death in the immediate family or serious illness of you or someone in your immediate family. Good cause
does not include travel for any reason other than death or serious illness as noted.
With your grievance request, you should tell BCBSAZ the action that you disagree with, the reason why you think BCBSAZ's action is wrong,
and what you are asking BCBSAZ to do differently. You should also send BCBSAZ any documents that support your request.
Note: Federal law has changed the health care appeals requirements for certain members enrolling in individual and family
insurance plans (not group sponsored plans) on and after September 23,2010. For these plans, the new HCR law allows only one level
of the BCBSAZ grievance process, which is final.
Because the new law allows only a single level of internal review, it is critical that members provide BCBSAZ with all relevant
documentation about their grievance (such as medical records and plysician letters), at the earliest stage of the process.
First Level Review
After receiving your grievance, BCBSAZ will review the situation, including any new information brought to BCBSAZ's attention.
BCBSAZ will notify you of its decision within thirty (30) days of receiving your grievance about a pre-service issue, and
within sixty (60) days of receiving your grievance about a claim or other post-service issue.
Voluntary Second Level Review May be Available
If you disagree with BCBSAZ's first level decision, you may send BCBSAZ a request for a second-level review.
The second level review is voluntary and is only available for policies issued before September 23, 2010¹.
You must file your request for second level review within sixty (60) days of receiving BCBSAZ's first level decision. You must explain the reason for your dissatisfaction with the first level decision, and any additional information you think should be considered.
Generally, a BCBSAZ appellate committee will review your grievance at a regularly scheduled meeting. The appellate committee includes BCBSAZ staff and administrators who did not make the initial decision, and may include external medical personnel. BCBSAZ will notify you of its second level decision within sixty (60) days of the date BCBSAZ receives your second level grievance. BCBSAZ may extend the second-level 60-day limit if necessary and in accordance with applicable law. BCBSAZ will notify you of any need for an extension.
Judicial Action (available to certain group participants)
Either at the conclusion of the first level review (if you choose not to pursue a voluntary second level review) or at the end of the second level review, if you are still dissatisfied with BCBSAZ's decision, you may pursue your judicial remedies by bringing a civil action under section 502(a) of ERISA (the Employee Retirement Income Security Act of 1974).
¹ Regardless of whether you choose to pursue this voluntary, second level review, BCBSAZ will not assert that you have failed to exhaust administrative remedies. We acknowledge that any statute of limitations is tolled during the time it takes for your second level review. Voluntary review will not affect your rights to any other benefits under this plan.