Resolving Problems for PPO and Traditional Members

If you have a problem with your Blue Cross Blue Shield of Michigan service, this information explains what you can do to resolve it.

Blue Cross Blue Shield of Michigan wants to make sure you're satisfied with the services you receive as a member. If you have a question or concern about how we processed your claim or request for benefits, contact customer service. You can find the number on the back of your member ID card. It's also at the top right-hand corner of your explanation of benefits statements.

Grievance and appeals process

If you were unable to resolve your concern through customer service, we have a formal grievance and appeals process. The length of time you have to file an appeal will depend on whether you're eligible for an appeal under a state or federal process.

Under either process, we won't charge you anything extra for filing a grievance or appeal. You may submit written materials or testimony to help us in our review at any step of the grievance or appeals process. You can use the Member Appeal Form (PDF) to submit your appeal. The form is optional. You can use it by itself or with a formal letter of appeal.

You can select someone to act on your behalf at any step of the grievance and appeals process, including your physician. Just fill out the Authorized Representative Form (PDF). This form gives your representative the permission to communicate with BCBSM on a one-time basis about your appeal.

State process

If you have individual, group or self-funded non-ERISA group coverage, you're eligible under the state process. You have 180 days from the date of discovery of a problem to file a grievance with, or appeal a decision of, BCBSM.

Under the standard internal grievance process, which includes a managerial-level conference, Blue Cross Blue Shield of Michigan must provide you with our final written determination within 60 calendar days of our receipt of your written grievance, unless you grant us additional time. The timeframe may be suspended for any amount of time that you are permitted to take to file your grievance, and for a period of up to 10 days if we have not received information we have requested from a health care provider, such as your doctor or hospital.

The standard internal grievance process is as follows:

  1. You or your authorized representative must send us a written statement explaining why you disagree with our determination on your request for benefits or payment. You can also use the Member Appeal Form (PDF) if you'd like. The form is optional and can be used by itself or with a formal letter of appeal.

    • Mail your written grievance to:
      Appeals Unit
      Blue Cross Blue Shield of Michigan
      600 E. Lafayette Blvd. 
      Mail Code 1620
      Detroit, MI 48226-2998
  2. Once we receive your request for an appeal, we will contact you to conduct or schedule the conference. That will be your opportunity to provide us with any additional information or testimony you want us to consider in reviewing your claim. You can ask that the conference be conducted in person or over the telephone. If in person, the conference can be held at our headquarters in Detroit, during regular business hours. Our written resolution will be our final determination regarding your grievance.
  3. If you disagree with our final determination, or if we fail to provide it to you within 60 days of the date we received your original written grievance, you may request an external review from the Department of Insurance and Financial Services.

You should also know

  • You may authorize another person to act on your behalf at any stage in the standard internal grievance procedure. You'll need to complete the Authorized Representative Form (PDF). You may authorize your physician or someone else to act on your behalf.
  • Although we have 60 days to give you our final determination, you have the right to allow us additional time if you wish.

Once you have exhausted Blue Cross Blue Shield of Michigan's standard internal grievance process, you or your authorized representative may request an external review. Depending on your plan, the review will be conducted by the Michigan Commissioner of Financial and Insurance Regulation or the Office of Personnel Management.

External review process for PPO and EPO members

The standard external review process is as follows:

  1. Within 120 days of the date you received our final determination or should have received it, send a written request for an external review to the commissioner.

    • Mail your request, including the required forms that we will supply to you, to:
      Office of Financial and Insurance Regulation
      Office of General Counsel
      Health Care Appeals Section
      P.O. Box 30220
      Lansing, MI 48909-7720
  2. If your request for external review concerns a medical issue and is otherwise found to be appropriate for external review, the commissioner will assign an independent review organization, consisting of independent clinical peer reviewers, to conduct the external review.

    • You will have an opportunity to provide additional information to the commissioner within seven days of submitting your request for an external review. We must provide documents and information considered in making our final determination to the independent review organization within seven business days after we receive notice of your request from the commissioner.

    • The assigned independent review organization will recommend within 14 days whether the commissioner should uphold or reverse our determination. The commissioner must decide within seven business days whether or not to accept the recommendation and will notify you. The commissioner's decision is the final administrative remedy under the Patient's Right to Independent Review Act of 2000.
  3. If your request for external review is related to nonmedical issues and is otherwise found to be appropriate for external review, the commissioner's staff will conduct the external review.

    • The commissioner's staff will recommend whether the commissioner should uphold or reverse our determination. The commissioner will notify you of the decision, and the commissioner's decision is your final administrative remedy under Public Act 350.

If a physician substantiates, either orally or in writing, that adhering to the timeframe for the standard internal grievance process would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, you may file a request for an expedited internal grievance.

You may file a request for an expedited internal grievance only when you think that Blue Cross Blue Shield of Michigan has wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service, or if you believe we have failed to respond in a timely manner to a request for benefits or payment.

The procedure is as follows:

  1. You may submit your expedited internal grievance request by telephone to 313-225-6800. The required physician's substantiation that your condition qualifies for an expedited grievance can also be submitted by telephone.

  2. We must provide you with our decision within 72 hours of receiving both your grievance and the physician's substantiation.

  3. If you do not agree with our decision, you may, within 10 days of receiving it, request an expedited external review from the Michigan Commissioner of Financial and Insurance Regulation.

You should also know

You may authorize another person, including your physician, to act on your behalf at any stage in the expedited internal grievance process. You'll need to complete the Authorized Representative Form (PDF) if you choose to do this. 

If you have filed a request for an expedited internal grievance, you may request an expedited external review. Depending on your plan, the review will be conducted by the Michigan Commissioner of the Department of Insurance and Financial Services or the Office of Personnel Management.

You may file a request for an expedited external review only when you think that Blue Cross Blue Shield of Michigan has wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service.

For members in multistate plans

If you don’t agree with our decision, you may ask for a free expedited external review from the Office of Personnel Management, or OPM. Anyone you’ve authorized to represent you can also request a review.

You can send your request by mail or email to one of the addresses below. Be sure to include a copy of our final determination with your request.

MSPP External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415

mspp@opm.gov

You’ll also need to submit an intake form. OPM will either give you the form or help you find it online. You choose how much information you want to include on the form. However, if you leave out necessary information, OPM may not conduct your review, or they may decide it adversely.

If you need help with the appeal process, contact the Office of Personnel Management at 1-855-318-0714. 

How OPM will use your information

OPM will use your information for general management of the external review system, including:

  • Determining if you’re eligible for external review
  • Conducting your external review
  • Giving you and Blue Cross Blue Shield of Michigan a record of the external review
  • Tracking and reporting on the external review system

OPM may disclose your records to:

  • Agency contractors, such as Independent Review Organizations, so they can conduct an external review.
  • The National Archives and Records Administration, or NARA, or the General Services Administration, or GSA, for records management.
  • OPM program and policy staff for statistical and analytical studies, or to plan health program changes.
  • Researchers inside and outside of the Federal Government looking at insurance trends and topical issues. OPM approves them in advance based on demonstrated aptitude and a written research plan.

OPM may also use your records for:

  • Responses to your congressional inquiries.
  • Investigations of potential violations of law, and judicial or administrative proceedings to which the Federal Government is a party. In this case, OPM may provide your information to another agency, a court, an administrative body or to the Department of Justice, when it’s relevant to the proceeding.
  • Investigations of data breaches and responses to data breaches.

How OPM will use your Social Security number

OPM may need your Social Security number, or SSN, to identify your unique records as authorized by Executive Order 9397. You’re not required to disclose your SSN. However, if you don’t provide it when requested, you may prevent or delay your review.

Documents submitted to OPM as part of your appeal may include your SSN. OPM will send a copy of any information you send to them to Blue Cross Blue Shield of Michigan.

Your right to request documentation

You have the right to ask for any documents related to the appeal decision free of charge. This could include things like:

  • Benefit provisions
  • Guidelines
  • Protocols
  • Medical policies
  • Diagnosis and treatment codes, and what they mean, unless precluded by other laws
  • The standard on which the adverse determination was based, if applicable

To request copies of these documents, please write to:

600 E. Lafayette Blvd
Mail Code 2004
Detroit, Michigan 48226-2998

OPM has the authority to administer the Multi-State Plan Program under section 1334 of the Affordable Care Act (42 U.S.C. 18054).

For all other PPO members

The expedited external review process is as follows:

  1. Within 10 days of your receipt of our denial, termination or reduction in coverage for a health care service, you or your authorized representative may request an expedited external review from the commissioner by calling 1-877-999-6442 to request the forms required.
  2. Mail your request, including the required forms that we will give you, to:
    Michigan Department of Insurance and Financial Services
    Office of General Counsel – Appeals Section
    P.O. Box 30220
    Lansing, MI 48909-7720
  3. Immediately after receiving your request, the commissioner will decide if it is appropriate for external review and assign an independent review organization to conduct the expedited external review. If the independent review organization decides that you do not have to first complete the expedited internal grievance procedure, it will review your request and recommend within 36 hours whether the commissioner should uphold or reverse our determination.
  4. The commissioner must decide within 24 hours whether or not to accept the recommendation and will notify you. The commissioner's decision is the final administrative remedy under the Patient's Right to Independent Review Act of 2000.

Federal process

If you have coverage through a self-funded ERISA group, you're eligible under the federal process. You have 180 days from the day we notified you of denial or reduction in payment on your claim to file an appeal with BCBSM.

Under the appeals process, we must provide you with our final written determination within 60 calendar days of Blue Cross Blue Shield's receipt of your written appeal, unless you grant us additional time. 

The internal appeals process is as follows:

  1. You or your authorized representative must send us a written statement explaining why you disagree with our determination on your request for benefits or payment. You can also use the Member Appeal Form (PDF) if you'd like. The form is optional and can be used by itself or with a formal letter of appeal.

    • Mail your written grievance to:
      DOL/ERISA Appeals
      Blue Cross Blue Shield of Michigan
      600 Lafayette East — Mail Code 1620
      Detroit, MI 48231-2998
  2. We will respond to your appeal in writing within 60 days. If you agree with our response, the appeal ends.
  3. If you disagree with our final determination, or if we fail to provide it to you within 60 days of the date we received your original written appeal, you may be eligible for an external review by an independent review organization.

You should also know

  • You may authorize another person (including your physician), to act on your behalf at any stage in the internal appeals process. You'll need to complete the Authorized Representative Form (PDF) if you choose to do this.
  • Although we have 60 days to give you our final determination, you have the right to allow us additional time if you wish.
  • You can request free copies of the actual benefit provisions, guidelines, protocols or medical policies that the appeal decision was based on. You can also request diagnosis and treatment codes and what they mean unless prohibited by law.
  • Although not required, you may also include notarized statements, declarations and testimony to support your appeal.
  • If you need assistance with the appeals process, you may contact a Blue Cross Blue Shield of Michigan representative by calling the number on the back of your member ID card.
  • There are also state and federal agencies available to assist you with any additional questions or assistance with the appeals process.
  • At the federal level, you can contact the Federal Employee Benefits Security Administration at 1-866-444-EBSA (3272).
  • At the state level, you can contact the Department of Insurance and Financial Services at 1-877-999-6442 or for general information, you can visit the Department of Insurance and Financial Services website.

Health care reform regulations provide for an external review process. Once you have exhausted Blue Cross Blue Shield of Michigan's internal appeals process, or we fail to provide you with a decision within the timeframe allowed by law, you or your authorized representative may be eligible for an external review by an independent review organization, or IRO, if the adverse determination on your claim involves medical judgment.

We will provide you with the appropriate form for requesting an external review, if applicable, when we notify you of our internal appeal determination. You can also access the Request for External Review Form (PDF).

The external review process is as follows:

  1. You must request the external review by an IRO within four months of the date you received our final adverse determination.

    • Mail the completed Request for External Review form, that we will supply to you, and a copy of the adverse benefit notification (the response letter to your internal appeal) to:
      BCBSM External Review Requests
      Blue Cross Blue Shield of Michigan
      600 Lafayette East — Mail Code 1620
      Detroit, MI 48226
  2. We will randomly assign your request for external review to a contracted independent review organization within five days of receiving your request for external review.
  3. The IRO will notify you whether your request is accepted for external review.
  4. If accepted, the IRO will provide you with its determination within 45 days of its receipt.
  5. If the IRO needs additional information, you will be contacted directly.

We will abide by the decision of the independent review organization and will pay your claim if the IRO determines that the services are a benefit based on their medical judgment.

If your request for benefits meets the definition of a preservice claim, meaning, you must obtain preapproval prior to receiving the service, and Blue Cross Blue Shield of Michigan denies your request for benefits, you may be eligible for an urgent expedited internal review if a physician substantiates either orally or in writing that adhering to the timeframe for the internal review process would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function.

You or your authorized representative may file a request for an urgent internal appeal only when you think that we have wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service, or if you believe we have failed to respond in a timely manner to a request for benefits or payment.

The urgent internal review process is as follows:

  1. You may submit your urgent internal appeal request by telephone. The required physician's substantiation that your condition qualifies for an expedited grievance can also be submitted by telephone.
  2. To initiate an urgent appeal, you may call the number included in the notice denying approval for the services.
  3. We will provide you with our decision within 72 hours of receiving both your urgent request and the physician's substantiation.
  4. If you do not agree with our decision, you may, within 10 days of receiving it, request an urgent external review.

You should also know

  • You may authorize another person (including your physician), to act on your behalf at any stage in the expedited internal grievance process. You'll need to complete the Authorized Representative Form (PDF) if you choose to do this.

If you have filed a request for an urgent internal review, you may request an urgent external review by an independent review organization.

You may file a request for an urgent external review only when you think that we have wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service.

The expedited external review process is as follows:

  1. Within 10 days of your receipt of our denial, termination or reduction in coverage for a health care service, you or your authorized representative may request an urgent external review by an independent review organization by writing to:
    BCBSM External Review Requests
    Blue Cross Blue Shield of Michigan
    600 Lafayette East — Mail Code 1620
    Detroit, MI 48231-2998
  2. You may also call 313-225-0646 to request the review.
  3. Immediately after receiving your request, we will randomly assign it to an independent review organization. The IRO will inform you directly of its decision within 72 hours of receiving your request for external review.

You should also know

You may authorize another person (including your physician) to act on your behalf at any stage in the expedited internal grievance process. You'll need to complete the Authorized Representative Form (PDF) if you choose to do this. 

To qualify for an urgent external review, all of the following requirements must be met:

  1. An internal urgent has been requested.
  2. The request for external review is within 10 days of receipt of an adverse determination.
  3. A physician substantiates the medical condition involved in the adverse determination is serious enough to jeopardize the life or health of the covered person.

State and federal process

For members who need to get approval for certain health services before receiving them.

If your health plan requires you to get approval for certain health services before receiving them and you disagree with Blue Cross Blue Shield of Michigan's decision not to approve a service, you have the right to appeal it.

Please follow the steps below to request a review. If you have questions or need help with the appeal process, please call the customer service number on the back of your Blue Cross ID card.

All appeals must be requested in writing.

For federal process: We must receive your written request within 180 days of the date you received notice that the service was not approved.

For state process: All appeals need to be requested in writing and should be submitted as soon as possible after you are notified that the service wasn’t approved.

To request a standard review

You, your doctor or someone else acting on your behalf can make the request. If someone else will represent you, that person needs to get your written permission. To do that, please call the customer service number on the back of your Blue Cross ID card and ask for a Designation of Authorized Representative and Release of Information form. Complete it and send it with your appeal.

Your letter requesting a review has to include the following information:

  • Your contract and group numbers from your Blue Cross ID card.
  • A daytime phone number for both you and your representative.
  • The patient's name if different from the member.
  • A statement explaining why you disagree with our decision and any additional supporting information.

Once we receive your appeal, we’ll give you our final decision within 30 days.

To request an urgent review

If your situation meets the definition of urgent under the law, your review will be conducted generally within 72 hours. An urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. If you believe your situation is urgent, you may request an urgent review. You may also request a simultaneous external review.

For more information on how to request an urgent review or simultaneous external review, call the customer service number listed on the back of your Blue Cross ID card.

For more information

At your request and without charge, we will send you details from your health care plan if our decision was based on your benefits. If our decision was based on medical guidelines, we will provide you with the appropriate protocols and treatment criteria. If we involved a medical expert in making this decision, we will provide that person's credentials.

To request information about your plan or the medical guidelines used, or if you need help with the appeal process, call the customer service number on the back of your member ID card.

Other resources to help you

For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). There is also a state agency available to assist you with any additional questions. You can contact the Office of Financial and Insurance Regulation's Michigan Health Insurance Consumer Assistance Program at 1-877-999-6442. For general information, visit the Department of Licensing and Regulatory Affairs website.

Mail or fax your appeal to one of the following

If your appeal is regarding specified organ or bone marrow transplants:

Human Organ Transplant Program
Blue Cross Blue Shield of Michigan
600 E. Lafayette
Mail Code 504C
Detroit, MI 48226
Fax: 1-866-752-5769

If your appeal is regarding an inpatient admission to a hospital, skilled nursing facility, or acute rehabilitation facility:

Precertification Medical Records and Appeals
Blue Cross Blue Shield of Michigan
P.O. Box 321095
Mail Code 511B
Detroit, MI 48232-1095
Fax: 1-877- 261-4555

If your appeal is regarding case management services:

Case Management Program
Blue Cross Blue Shield of Michigan
600 E. Lafayette
Mail Code 504A
Detroit, MI 48226-2998
Fax: 1-866-643-7057

If your appeal is regarding a prescription drug:

Pharmacy Services
Blue Cross Blue Shield of Michigan
Pharmacy Services
P. O. Box 2320
Detroit, MI 48231-2320
Fax: 1-866-612-0627

Questions?

Privacy issues: To report a concern or if you think your protected health information has been compromised, please call us at 1-800-552-8278 or email us. Don't include any protected health information in your email. 

Other issues: For customer service, call the number on the back of your member ID card.