Appeals and Grievances

Appeals are formal requests to challenge a coverage decision for services or drugs you may be entitled to receive. This includes any delays in providing, arranging, or approving healthcare services or drugs, as well as any amounts you must pay for these services or drugs.

There are several steps (or levels) of an Appeal, which include:

• A plan reconsideration or redetermination
• A second level review of the plan's decision by a Medicare-contracted independent reviewer
• A hearing with an Administrative Law Judge (ALJ) or attorney adjudicator
• A review by the Medicare Appeals Council (MAC)
• A judicial review

Instructions on how to appeal are included when you receive a letter denying coverage and in your Evidence of Coverage (EOC).

Grievances express dissatisfaction with any part of AZ Blue or its delegates' healthcare services or prescriptions, regardless of whether action can be taken. Grievances are different from appeals or disputes about coverage determinations (for medical services or prescription drugs) or late enrollment penalties. Members can file grievances by phone or in writing using the contact information below.

Members can file an appeal or grievance by phone, mail, or by filling out the online form below.

Online:
Click here to fill out the online form for submission.

Mail:
Download and fill out the Appeal and Grievance form (English, Español) and mail or fax to the contact information below.

If you have concerns about the quality of care or other services you received from any of our providers, please contact Member Services at 480-937-0409 (in Arizona) or toll-free at 1-800-446-8331 (TTY: 711). You may also file a complaint at Medicare.gov

If you have questions or concerns or want to check the status of coverage determinations, appeals, or would like to file a grievance; have questions about making an AOR; or need help in completing the AOR form; please call Member Services at the phone number listed above. 

Acceptable forms of authorization documentation:

• Power of attorney (POA) documentation
• Document showing an individual authorized by a court or authorized under State or other applicable law. An authorized individual can include, but is not limited to, a court-appointed guardian, an individual with durable power of attorney, a healthcare proxy, a person designated under a healthcare consent statute, or an executor of an estate. Legal authorization documentation is valid until its expiration date noted in the document, unless revoked.
• Completed Appointment of Representative (AOR) form (English, Español). A completed AOR form is valid for one year from the date it has signatures for you and your appointee, unless revoked.
• Equivalent written notice which includes:
  • Your name, address, and telephone number
  • Appointed individual’s name, address, and telephone number
  • Your Medicare beneficiary identifier (MBI) or plan ID number
  • Appointed individual’s professional status or relationship to you
  • Written explanation of the purpose and scope of the representation
  • Statement that you authorize the appointed individual to act on your behalf
  • Statement authorizing disclosure of individually identifying information to the appointed individual
  • Statement by the individual being appointed that they accept the appointment
  • Signature and signature date by you and the individual being appointed. An equivalent notice is valid for one year from the date it has signatures for both you and your appointee, unless revoked