What is an appeal?

An appeal is an action you may take if you think we made a mistake or if you disagree with our coverage or payment decision. It is a formal way of asking us to review and change a coverage decision we have made. You can appeal if your plan denies one of these:

  • Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
  • Your request for payment for a health care service, supply, item, or prescription drug you already got
  • Your request to change the amount you must pay for a health care service, supply, item, or prescription drug

You must ask for an appeal within 60 calendar days from the date on the decision letter we send you. If you miss the deadline for a good reason, you may still appeal.

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal.

If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your Member rights and responsibilities for information about your appeal rights.

Submit an appeal online

Download appeal form (PDF, 197 KB)

See our step-by-step instructions on how to submit Level 1 and Level 2 appeals.

Level 1 appeal process

Step 1

To start your Level 1 appeal, you, your representative, your doctor, or other prescriber must contact us within 60 calendar days from the date of the decision letter we sent you. If your health requires a quick response, you must ask for a "fast appeal." You may contact Blue Shield of California Promise Health Plan Member Services via toll-free number, fax, by mail, or submit your appeal online.

  Phone:(800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week, from October 1 to March 31, and Monday through Friday, from April 1 to September 30.
  Fax: (323) 889-5049
  Blue Shield of California Promise Health Plan
Member Appeals and Grievances (Complaints) Department
601 Potrero Grande Dr.
Monterey Park, CA 91755

When your complaint is about quality of care, you also have two extra options:

  1. You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). Livanta is California's QIO.

      Phone: (877) 588-1123 (TTY: (855) 887-6668)
      Livanta BFCC-QIO Program
    10820 Guilford Road, Suite 202
    Annapolis Junction, MD 20701

  2. Or if you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization.

For expedited requests (“fast appeal”), call or fax Blue Shield of California Promise Health Plan Member Services using the contact numbers above.

Step 2

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We may contact you or your doctor or other prescriber to get more information.

Fast appeal for medical coverage

When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.

  • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing.
  • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. (See Level 2 Appeals Process)
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 appeal.

Fast appeal for drug coverage

If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

  • If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.

Standard appeal for medical coverage

For standard appeals, we will give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give your our answer within 60 calendar days if your appeal is for payment for services you have already received. We will give you our decision sooner if your health condition requires us to.

  • However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter.
  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.

Standard appeal for drug coverage

For standard appeals, we will give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

  • If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
  • If our answer is yes to part or all of what you requested, we will do the following:
    • If the request is for prescription coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
    • If the request is to pay you back for a drug you already bought, we are required to reimburse you within 30 calendar days after we receive your appeal request.

Step 3

If our plan says no to part or all of your appeal, for medical services, your case will automatically be sent on to the next level of the appeals process, and for drugs, you will need to decide if you want to continue with the process and make another appeal.

For medical coverage

We are required to send your appeal to the Independent Review Organization. When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

For drug coverage

If we say no to your Level 1 appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.

Learn about Level 2 Appeal process

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at (800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week, from October 1 through March 31, and Monday through Friday, from April 1 through September 30.