Part 8 Grievance Program You have the right to a review when you disagree with a decision by Blue Cross and Blue Shield to deny payment for services that may be eligible for benefits under Medex, or if you have a complaint about the care or service you received from or a Blue Cross and Blue Shield covered provider. When making a determination under this Medex plan, has full Blue Cross and Blue Shield discretionary authority to interpret this Benefit Description and to determine whether a health service or supply is a under this Medex plan. All determinations by covered service Blue Cross with respect to benefits under this Medex plan will be conclusive and binding and Blue Shield unless it can be shown that the interpretation or determination was arbitrary and capricious. Making an Inquiry and/or Resolving Medex Claim Problems or Concerns Most Medex problems or concerns can be handled with just one phone call. (See page 2 for more information about Member Services.) For help resolving a Medex problem or concern, you should first call the customer service office at 1-800-258-2226. Or, if Blue Cross and Blue Shield a different telephone number appears on your Medex identification card, you may call that number. A customer service representative will work with you to help you understand your Medex benefits or resolve your problem or concern as quickly as possible. When resolving a problem or concern, will consider all aspects of the Blue Cross and Blue Shield particular case, including the terms of your benefits as described in this Benefit group Description, policies and procedures that support the administration Blue Cross and Blue Shield of these benefits, the provider’s input, as well as your understanding and expectation of benefits. will use every opportunity to be reasonable in finding a solution that Blue Cross and Blue Shield makes sense for all parties and may use an individual case management approach when it is judged to be appropriate. will follow its standard business practices Blue Cross and Blue Shield guidelines when resolving your problem or concern. If you disagree with the decision given to you by the customer service representative, you may request a review through the formal internal grievance program as described below. Note: has its own policies and procedures for handling appeals and grievances. See Medicare Appeals and Grievances” below for information about resolving problems Medicare “Medicare and concerns. (Medicare has its own policies and procedures for handling appeals and grievances. See Appeals and Grievances” below for information about resolving “Medicare problems and concerns.) Medicare
Part 8 Grievance Program You have the right to a review when you disagree with a decision by Blue Cross and Blue Shield to deny payment for services that may be eligible for benefits under Medex, or if you have a complaint about the care or service you received from Blue Cross and Blue Shield or a covered provider. When making a determination under this Medex plan, Blue Cross and Blue Shield has full discretionary authority to interpret this Benefit Description and to determine whether a health service or supply is a covered service under this Medex plan. All determinations by Blue Cross and Blue Shield with respect to benefits under this Medex plan will be conclusive and binding unless it can be shown that the interpretation or determination was arbitrary and capricious. Making an Inquiry and/or Resolving Medex Claim Problems or Concerns Most Medex problems or concerns can be handled with just one phone call. (See page 2 for more information about Member Services.) For help resolving a Medex problem or concern, you should first call the Blue Cross and Blue Shield customer service office at 1-800-258-2226. Or, if a different telephone number appears on your Medex identification card, you may call that number. A customer service representative will work with you to help you understand your Medex benefits or resolve your problem or concern as quickly as possible. When resolving a problem or concern, Blue Cross and Blue Shield will consider all aspects of the particular case, including the terms of your group benefits as described in this Benefit Description, Blue Cross and Blue Shield policies and procedures that support the administration of these benefits, the provider’s input, as well as your understanding and expectation of benefits. Blue Cross and Blue Shield will use every opportunity to be reasonable in finding a solution that makes sense for all parties and may use an individual case management approach when it is judged to be appropriate. Blue Cross and Blue Shield will follow its standard business practices guidelines when resolving your problem or concern. If you disagree with the decision given to you by the customer service representative, you may request a review through the formal internal grievance program as described below. Note: Medicare has its own policies and procedures for handling appeals and grievances. See “Medicare Appeals and Grievances” below for information about resolving Medicare problems and concerns. (Medicare has its own policies and procedures for handling appeals and grievances. See “Medicare Appeals and Grievances” below for information about resolving Medicare problems and concerns.)
ascme2-0601.docx