Blue Cross (Anthem) appeal process

I decided to be proactive about my appeal instead of waiting around for the denial letter, so I called Anthem Blue Cross to inquire. They said that Joanna from Dr. Delamarter's office called on 7/14 for the preauthorization (BC preauth. 1-800-451-6780). BC called back on 7/18 with a denial on the grounds of the procedure being "experimental / investigative." I should receive a denial letter within 3-5 business days. This letter is also sent to Delamarter and the hospital (St. John's, Santa Monica). To expedite the process, I then contacted the BC Appeals Dept. (1-800-365-0609). They said I needed to either file my appeal online, via telephone, or fax to Anthem Blue Cross Grievance and Appeals Dept. at FAX: (818) 234-3824. I need to include my member ID number as well as any supporting information (e.g., doctor's letters) to support my claim.

from Blue Cross Grievance:

How to file a Grievance

Anthem Blue Cross shall ensure that all enrollees have access to and can fully participate in the grievance system by providing assistance for those with limited English proficiency or with visual or other communicative impairment. Such assistance shall include, but not be limited to, translations of grievance procedures, forms and plan responses to grievances, as well as access to interpreters, telephone relay systems and other devices that aid disabled individuals to communicate.

Anthem Blue Cross has a formal process for reviewing member complaints or grievances. This process provides a uniform and equitable treatment of your complaint or grievance and a prompt response.

Standard Grievance Review

Steps in the process

1. File your grievance or complaint with Anthem Blue Cross. You may also authorize someone to represent you. Authorization must be in writing. Call customer service for the authorization form. Your customer service number is on the back of your membership card.

You can file your grievance by:

a. Calling customer service. Your customer service number is on the back your
membership card.

b. Mailing a letter or a completed grievance form which you can get on to website
or by calling customer service or

c. Submitting a grievance form online.

2. We will send you an acknowledgement letter within five (5) calendar days of receipt.

3. We will review your grievance. The process varies by the nature of the grievance. Medical grievances are reviewed by staff medical personnel and some are referred to physician medical specialists. Some types of medical grievances are reviewed twice by two different doctors to ensure that the right decision has been made about your medical coverage. Non-medical grievances are reviewed by grievance specialists. We will provide a written response to you within 30 calendar days after we receive your grievance.

4. If you are dissatisfied with our answer, you may be able to pursue one or more of the following appeal processes, depending on your situation and the appeal information contained in your Evidence of Coverage. If you need assistance please contact customer service at the number on the back of your membership card.

a. File a complaint with the Department of Managed Health Care (DMHC)
provided that your Anthem Blue Cross health coverage is governed by
them. Click here for a link to the DMHC web site. Your grievance
acknowledgement letter and response letter from Anthem Blue Cross will include
information on how to contact the Department of Managed Health Care.

If your health coverage is not governed by the DMHC, it may be governed by the
Department of Insurance. Please contact customer service if you are not sure
which entity governs your health coverage. Your customer service number is on
the back of your membership card.

b. Submit a request for binding arbitration. Not all Anthem Blue Cross members
may request binding arbitration. The right to request binding arbitration is
explained in your Evidence of Coverage.

c. Request Independent Medical Review. Independent Medical Review is
available for decisions to deny payment on the basis that the services are not
medically necessary or that they are considered investigational or experimental. If
you are eligible for Independent Medical Review, information will be provided in
our letters to you.

d. Have your case reviewed in an administrative hearing if you are a Medicare
beneficiary or a MediCal enrollee. Those rights are identified in your Evidence of
Coverage.

e. Seek legal remedies in a court of law.

Expedited Review

An expedited review is available when a medical decision has been made to deny a payment and there is "an imminent and serious threat to the health of the enrollee, including but not limited to, serious pain, potential loss of life, limb or major bodily function."

Steps in the process

1. File your grievance or complaint with Anthem Blue Cross using one of the methods listed in the standard grievance process. You may also authorize someone to represent you. Authorization must be in writing. Contact customer service for the authorization form. Your customer service number is on the back of your membership card. Calling customer service is the recommended method of requesting an expedited review.

2. A physician will review your request and make a determination within 72 hours. If your request does not qualify for an expedited review, your grievance will be reviewed in the standard 30-day grievance process. You will be notified by mail if you do not qualify for expedited review.

3. If you qualify for Independent Medical Review, you may appeal directly to the Department of Managed Health Care immediately.

File Online Grievance

Forms :

Grievance Spanish

Grievance English