What is an appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. If you or your doctor or other provider disagrees with our decision, you can appeal.

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss the deadline for a good reason, you may still appeal. You will receive a letter from us within 5 calendar days of receiving your appeal letting you know that we received it. See below for instructions on how to start an appeal.

Submit an appeal online

Download appeal form (PDF, 61 KB)

Here is the step-by-step process for Level 1 Appeal.

Level 1 appeal process

Step 1 – You contact us and make your Level 1 Appeal.

To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.

  • Call Blue Shield Promise Cal MediConnect Plan Member Services:
      Phone:(855) 905-3825 [TTY: 711], 8 a.m. – 8 p.m., seven days a week.
  • Send a fax to Blue Shield of California Promise Health Plan
      Fax: (323) 889-5049
  • Write to Blue Shield of California Promise Health Plan at this address:
      Blue Shield of California Promise Health Plan
    Member Appeals and Grievances (Complaints) Department
    601 Potrero Grande Dr.
    Monterey Park, CA 91755

If your health requires a quick response, you must ask for a "fast appeal." For expedited requests (“fast appeal”), please call or fax using the contact numbers above.

NOTE: You are not required to appeal to the plan for Medi-Cal services including long-term services and supports. If you do not want to first appeal to the plan, you can ask for a State Fair Hearing or, in special cases, an Independent Medical Review.

Step 2 – We consider your appeal and we give you our answer

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.

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 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 we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself.
  • If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get 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.

Fast appeal for medical coverage

If you ask for a fast appeal, we will give you your answer within 72 hours after we get 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, 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 we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself.
  • If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.
  • If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself.

Fast appeal for drug coverage

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

  • If we do not give you an answer within 72 hours, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision.
  • If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal.
  • If our answer is No to part or all of what you asked for, we will send you a letter that explains why we we denied the service and provide you instructions on your next steps.

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. Or,
  • If the request is to pay you back for a drug you already bought, we are required to send payment to 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 coverage

If we say No to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal.

If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete.

If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this.

For drug coverage

If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity will review our decision.