Appeals and Grievances

Complaints, Grievances, Informal Reconsideration and Appeals

What is a complaint?
A complaint is an oral expression of dissatisfaction with us or provider services. A quality of care concern addresses the appropriateness of care given to you. A quality of service concern addresses our services, access, availability or attitude of our network providers.

How to register a complaint.
To register a complaint, call the Customer Service phone number on the back of your I.D. card and we will attempt to resolve your complaint at the time of your call. Hearing Impaired Callers contact Louisiana Relay Service at 1.800.846.5277 (TTY) for assistance. Provide LRS with 1.800.599.2583 as the number they use to direct your call to the correct Blue Cross department.

What is a formal grievance?
A grievance is a written expression of dissatisfaction with us or provider services. If you do not feel your complaint was adequately resolved over the phone or you wish to file a formal grievance, you must submit this in writing. If necessary, our Customer Service Department will assist you.

How to file a formal grievance.
Your written grievance must be sent to:

Blue Cross and Blue Shield of Louisiana - Customer Service Unit
Appeals and Grievance Coordinator
P. O. Box 98045
Baton Rouge, LA 70898-9045

Please include:

            Subscriber Name
            Subscriber ID #
            Member's Name
            The nature of the grievance 
            Any other information that may be helpful for the review

A response will be mailed to you within 30 business days after we receive your written grievance. If you are not happy with our handling of your grievance, you have the right to elevate your grievance to the second and final level. Each level of the grievance procedure is reviewed by a separate panel.

What is an informal reconsideration?
In cases involving medical necessity determinations, in addition to the appeals rights, your provider is given an opportunity to speak with a Medical Director for an informal reconsideration of our coverage decision.

An informal reconsideration is your provider's telephone request to speak to our Medical Director or a peer reviewer on your behalf about a utilization management decision that we have made. An informal reconsideration is typically based on submission of additional information or a peer-to-peer discussion. An informal reconsideration is available only for initial or concurrent review determinations that are requested within 10 days of the denial. We will conduct an informal reconsideration within one working day of the receipt of the request.

What is an appeal?
An appeal is a written request to change a prior decision that we have made. We recognize that disputes may arise between us and our members or insureds regarding coverage decisions. We consider any request to change our coverage decision as an appeal. Examples of issues that qualify as appeals include denied authorizations, denied claims, and medical necessity determinations. We will distinguish your appeal as either an administrative appeal or a medical necessity appeal.

If you are not satisfied with the outcome of an appeal, depending upon the circumstances, you may be entitled to additional appeal(s) under your policy or contract and/or applicable law. You should consult your policy or contract regarding such appeals.

You are encouraged to provide us with all available information and submit our appeal request form in a timely manner to help us completely evaluate your appeal. Call the Customer Service phone number on the back of your I.D. card for more detailed information on appeals. Hearing Impaired Callers contact Louisiana Relay Service at 1.800.846.5277 (TTY) for assistance. Provide LRS with 1.800.599.2583 as the number they use to direct your call to the correct Blue Cross department.