What to do if you’re unhappy with your care or service
This process applies if you’re covered by Anthem Blue Cross or Anthem Blue Cross Life & Health Insurance Company (Anthem). To find out, check your member ID card.
If you are unhappy with the care or service you received from Anthem or a network medical group or health care provider, you can file a complaint. We call this a “grievance.” If you disagree with a denial of treatment or claims payment, you can “appeal” the decision.
You have up to 180 calendar days from the date you get a denial notice or the date of an incident or dispute to file a grievance or appeal unless your plan documents say otherwise. If there is a good reason, we may give you more time to file a grievance or appeal.
How to submit a grievance or appeal:
- Member Grievance Form: Complete a Member Grievance form and mail it to: Anthem Blue Cross Life and Health Insurance Company PO Box 54159 Los Angeles CA 90054
- Website: Go to anthem.com/ca and download the grievance or appeal form.
- Member Services : Call Member Services at the number on your ID card to file a grievance or appeal.
The form is available from your medical group, on our website or by calling Member Services at the number on your member ID card.
For emergency complaints
For any emergency grievance or appeal, call Member Services right away at the toll-free number on your member ID card.
You can choose anyone you want including an attorney or health care expert to file a grievance or appeal for you. You will be asked to fill out and sign an authorization form so that person can represent you.
What to include with your appeal
You should include with your appeal (if available):
- Your name and ID number;
- The name of the provider or facility that provided care;
- The date(s) of service;
- The claim or reference number for the specific decision with which you disagree;
- The reason(s) why you do not agree with the decision
You have the right to include written comments, documents or other key information with your appeal. We encourage you to do so.
What happens next?
- The proper administrative and/or clinical specialists will review all information you or your representative submit with your appeal. Anthem appeal reviewers cannot have been involved in the initial decision. They also can’t work for the person who made the initial decision.
- We may contact any providers who may have more information to support your appeal.
- We will send you a written decision within 30 calendar days of getting your grievance or appeal. If your condition is urgent, you can ask for an expedited review of your grievance or appeal. Anthem will then provide you and your provider with a verbal decision within 72 hours, followed by a written decision within 3 calendar days of our receipt of your grievance or appeal.
- If we deny your appeal, we give you other options, including external review, if available. You also can check your plan documents or call Member Services at the number on your member ID card to get more information about the appeal process.
Do you speak another language
We can help you or any member who prefers to speak in a language other than English and those with vision, speech or hearing loss by providing:
Call Member Services
If you or a representative filed a grievance or appeal, you can call Member Services at the number on your member ID card with any questions or requests for information about your case.
*To identify the company that provides your plan, check your member ID card
Are you an ERISA plan member?
If your health benefit plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), once you have exhausted all mandatory appeal rights, you have the right to bring a civil action in federal court under section 502(a)(1)(B) of ERISA within one year, unless your plan provides for a longer period. Check your benefits booklet or plan documents to see if you have more time.