Grievances And Appeals

If you are unhappy with Anthem Blue Cross and Blue Shield or our providers, or do not agree with a decision we made, contact us as soon as possible. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to provide us your written consent. Anthem wants to help.

Grievances - (Also Called Complaints)

 

If you have a problem with our services or network providers, we would like you to tell us about it. Please call Member Services and we will try to solve your problem on the phone.

 

If we cannot take care of the problem when you call us, you can file a grievance.

 

You can also file a grievance by:

 

After we receive your grievance, Anthem will:

  1. Send you a letter within three calendar days to let you know we received your grievance.
  2. Look into your grievance in a timely manner.
  3. Let you know our decision depending on the issue within 30–60 calendar days of when you first told us about your grievance. If you are unable to get care, we will contact you within two business days.

 

If you are not happy with the response of your Anthem grievances or our process, you may ask for a state fair hearing. See the section Fair Hearings for more details.

 

 

Medical Appeals

 

There may be times when Anthem will deny, end, or reduce a service you or your provider has requested. We may also say we will not pay for all or part of the care your provider asked for. Anthem will send you a letter called a Notice of Action. If you do not agree with the decision or action listed in the letter, you can contact us within 60 calendar days to ask for an appeal.

 

For standard approval requests, Anthem has 15 calendar days to respond and either approve or deny the service request. For expedited (rushed) approval requests, when you need a quick response, Anthem has 72 hours or less to respond and either approve or deny the service request. If Anthem is reducing or ending a previously authorized service, we must send you a Notice of Adverse Benefit Determination at least 10 days before the date we plan to reduce or end the covered service.

 

If Anthem sends you a Notice of Adverse Benefit Determination, you can appeal the decision. Your provider can appeal our decision for you if they have your written permission.

 

A medical appeal is when you ask us to look again at the care we said we would not pay for. You must file for a medical appeal within 60 calendar days from the date on the Notice of Adverse Benefit Determination letter. A medical appeal can be filed by:

  • You.
  • A person helping you.
  • Your provider taking care of you at the time. If you want your provider to file an appeal for you, they must have your written permission. 

 

To continue receiving services we have already approved and are now denying, you or your provider must complete a Request to Continue Benefits during an Appeal or Fair Hearing on or before the later of: 

  • 15 calendar days after we mail the denial notice. 
  • The date the notice says your service will end.

 

You can appeal our decision in several ways:

  • Directly submit your appeal from by logging into the secure member portal or the mobile app. Look for Appeals under Support.
  • An appeal form will be attached to the Notice of Action letter.
  • If you need someone else to help you with the appeal process, such as a family member, friend, or the provider taking care of you, call Member Services and ask to appeal.

 

You can also have your provider file the appeal for you with your medical records. You will need to give your provider permission by signing the form. You or your provider can also mail the form to: 

 

Medical Appeals

Anthem Blue Cross and Blue Shield 

P.O. Box 62509

Virginia Beach, VA 23466

 

We will send you a letter within three calendar days from when we receive your request to let you know we got your request for an appeal or within 24 hours if you asked for an expedited appeal. See the section called Expedited Appeals for more details.

 

After we receive your appeal:

  • A different provider than the one who made the first decision will look at your appeal. 
  • We will send you and your provider a letter telling you our decision within 15 calendar days from when we receive your appeal or within 72 hours if you asked for an expedited appeal. See the section called Expedited Appeals for details. 

 

We will tell you and your provider how to find out more about the decision. We will tell you your rights to request a state fair hearing if you don’t agree with our decision. You may also request a copy (free of charge) of the documents used to make the appeal decision, including your medical records, actual benefit provision, guideline, protocol, or criteria we based our decision on.

 

If we need more information about your appeal:

  • We may ask for medical records to help us make a decision. You, or your provider giving you care, must forward the records to us. Upon state approval or your request, we may extend the appeal process up to 14 calendar days if it is in your best interest.
  • If the state approves our extension request, we will let you — or the person you asked to file the appeal for you — know in writing within two calendar days the reason for the delay. If you are not happy with the extra time we need to complete the review, you can file a grievance about the delay. 

 

You may ask us to extend the process if you know more information that we should consider.

 

After you have completed the Anthem appeal process, and you still do not agree with our decision, you may ask for a state fair hearing. See the section Fair Hearings for more details.

 

 

Expedited Appeals

 

You or the person you ask to file an appeal for you can request an expedited appeal. You can request an expedited appeal if you or your provider feels that taking the time for the standard appeals process could seriously harm your life or your health.

 

You or your provider can request an expedited appeal. Call Member Services toll-free at 844-912-0938 (TTY 711), Monday through Friday from 8 a.m. to 7 p.m. Eastern time. When we receive your call, we will call you within 72 hours to tell you our decision. 

 

You may also ask us to extend the process if you have more details that we should review. 

 

If we don’t agree that your request for an appeal should be expedited, we’ll:

  • Call you right away.
  • Send you a letter within two calendar days to let you know how the decision was made, and that your appeal will be reviewed through the standard review process of 14 calendar days.

 

If the decision on your expedited appeal is the same as our first decision and we will not pay for the care your doctor asked for, we will call you and send you a letter. This letter will:

  • Let you know how the decision was made.
  • Tell you about your rights to request an expedited state fair hearing.

 

 

Fair Hearings

 

State Hearings

 

A state hearing is a meeting with you or someone you want to speak on your behalf, someone from the County Department of Job and Family Services, someone from Anthem, and a hearing officer from the Bureau of State Hearings within the Ohio Department of Job and Family Services (ODJFS). In this meeting, you will explain why you think Anthem did not make the right decision and Anthem will explain the reasons for making our decision. The hearing officer will listen and then make a decision based on the rules and the information given.

 

Anthem will notify you of your right to request a state hearing if:

  • We do not change our decision or action because of your appeal.
  • A decision is made to propose enrollment or continue enrollment in the [coordinated services program (CSP)].
  • A decision is made to deny your request to change your coordinated services program provider.  

 

You may only request a state hearing after you have gone through Anthem’s appeal process.

 

If you want a state hearing, you, or someone you want to speak on your behalf, must request a hearing within 120 calendar days. The 120-calendar day period begins on the day after the mailing date on the hearing form. If your appeal was about a decision to reduce, suspend, or stop services before all the approved services are received, your letter will tell you how you can keep receiving the services if you choose to and when you may have to pay for the services. If we propose to enroll you in the coordinated services program and you request the hearing within 15 calendar days from the mailing date on the form, we will not enroll you in the program until the hearing decision.

 

 

To Request A Hearing

 

You can:

  • Sign and return the state hearing form to the address or fax number listed on the form.
  • Call the Bureau of State Hearings at 866-635-3748.
  • Submit your request via email at bsh@jfs.ohio.gov.

 

If you want information on free legal services but don’t know the number of your local legal aid office, you can call the Ohio State Legal Services Association at 800-589-5888.

 

State hearing decisions are usually issued no later than 70 calendar days after the request is received.  However, if MCO or the Bureau of State Hearings may decide that the health condition meets the criteria for an expedited decision. An expedited decision will be issued as quickly as needed but no later than three working days after the request is received. Expedited decisions are for situations when making the decision within the standard time frame could seriously jeopardize your life, your health, or your ability to attain, maintain, or regain maximum function.

 

Anthem will pay for services you receive during the time your benefits were continued until a final decision is made. You may have to pay for the cost of any continued benefit if the final decision isn’t in your favor.

 

If a decision is made in your favor as a result of your appeal or fair hearing, we will authorize and pay for the services we denied coverage of before as expeditiously as possible but no later than 72 hours from the date we are notified of the decision.

 

 

Provider Payment Appeals

 

If you receive a service from a provider and we do not pay for that service, you may receive a notice from Anthem called an Explanation of Benefits (EOB). This isn’t a bill. The EOB will tell you:

  • The date you received the service.
  • The type of service.
  • The reason we can’t pay for the service.

 

If you receive an EOB, you don’t need to call or do anything at that time, unless you want to appeal the decision.

 

A payment appeal is when your provider asks Anthem to look again at the service we said we would not pay for. Your provider must ask for a payment appeal within 60 calendar days of receiving the EOB.

 

Payment appeals must be submitted in writing by your provider.