As a Blue Shield of California plan member, you are guaranteed your right to file a complaint if you have concerns or problems with any part of your care. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way for filing a complaint.

We encourage you to let us know right away if you have questions, concerns or problems related to your Prescription Drug coverage, covered services or the care you receive. Comments are utilized to help improve the services provided to you.

There are two types of complaints you can make. The type of complaint you file depends on your situation.

Appeals

An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what services and/or drugs are covered for you or how much we will pay for a service and/or drug.

You must file the appeal request within 60 calendar days from the date included on the organizational determination notice (denial letter or coverage determination). We may give you more time if you have a good reason for missing the deadline.

To ask for a standard appeal, you or your appointed representative must send a written appeal request stating the nature of the complaint to the address listed below.

An appeal can be filed online using our Appeals and grievances online form. Read more about filing a complaint with Blue Shield.

For a decision about payment for services you already received: After we receive your appeal, we have 60 calendar days to reconsider our decision. If we find in your favor, we must issue payment within 60 calendar days of the date of receipt of your appeal request.

For a standard decision about authorizing medical care: After we receive your appeal, we have up to 30 calendar days to make a decision, but will make it sooner if your health condition requires.

For a decision about payment for Part D prescription drugs you already received: After we receive your appeal, we have seven calendar days to make a decision. If we find in your favor, we have 30 days from the date of receipt of your appeal request to issue payment.

For a standard decision about Part D prescription drugs: After we receive your appeal, we have up to seven calendar days to make a decision, but will make it sooner if your health condition requires.

If you or your doctor believes that waiting for a standard appeal decision could seriously harm your health or ability to function, you may ask for an expedited “fast” appeal. To ask for an expedited "fast" appeal, you, your doctor, other prescriber, or authorized representative, will need to call, fax or write to us at the numbers or address listed below. If you are given an expedited "fast" appeal, we will give you our decision within 72 hours after receiving the request. We will give you the decision sooner if your health condition requires us to.

We may extend the timeframe of your appeal by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If we do not give you our decision within the appropriate appeal timeframe, your request will automatically be forwarded to an independent organization who will review your case.

If we deny your medical appeal, we will automatically forward your case to an independent review entity to review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets the minimum requirement. You will be notified of your appeal rights if this happens.

There is another special type of appeal that applies only when coverage will end for Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Comprehensive Outpatient Rehabilitation Facilities (CORF) services. If you think your coverage is ending too soon, you can appeal directly and immediately to Health Services Advisory Group, which is the Quality Improvement Organization in the state of California. If you get the notice two days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice. If you get the notice and you have more than two days before your coverage ends, then you must make your request no later than noon of the day before the date that your Medicare coverage ends.

 

Grievances

grievance is the type of complaint you make if you have any other type of problem with a Blue Shield of California Medicare Plan or one of our providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office.

Our Grievance Process consists of two steps:

Step 1: File a Grievance

To begin the process, call a Member Services representative within 60 days of the event and ask to file a Grievance. You may also file a Grievance in writing within 60 days of the event by sending it to the address below.

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

If you ask for a "fast grievance" because we decided not to give you a "fast decision" or "fast appeal" or because we asked for an extension on our initial decision or fast appeal, we will forward your request to a Medical Director who was not involved in our original decision. We may ask if you have additional information that was not available at the time you requested a "fast initial decision" or "fast appeal."

The Medical Director will review your request and decide if our original decision was appropriate. We will notify you of our decision within 24 hours of your request for a "fast grievance."

Step 2: Grievance Hearing

If you are not satisfied with this resolution, you may make a written request to Blue Shield of California Medicare Appeals & Grievances for a Grievance hearing. Within 31 days of your written request, we will assemble a panel to hear your case. You will be invited to attend the hearing, which includes an uninvolved physician and a representative from the Appeals and Grievance Resolution Department. You may attend in person or by teleconference. After the hearing, we will send you a final resolution letter.

 

Filing a Grievance With Our Plan 

If you have a complaint, please fill out our Appeals and Grievances Form online. We will mail you a written outcome when our review of your request is completed. We will contact you directly if additional information is needed to process your request.

You can also call us to file a complaint using the phone numbers below.

Blue Shield 65 Plus, Blue Shield 65 Plus Choice Plan and Blue Shield Trio Medicare members:

(800) 776-4466 [TTY 711] between 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday) from April 1 through September 30.

Blue Shield Medicare Prescription Drug Plan members:

(888) 239-6469 [TTY 711] between 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday) from April 1 through September 30.

​We will try to resolve your complaint over the phone. If you ask for a written response, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.

You may mail your appeal or grievance via a written letter or by using one of our forms. Please mail or fax to:

Blue Shield of California Medicare Appeals & Grievances

PO Box 927, Woodland Hills CA 91365-9856

By Fax: (916) 350-6510

If contacting us by fax or by mail, please download and complete a Blue Shield of California Appeals & Grievances Form. ( PDF , 29KB )

 

Additional information

For more detailed information on how the exceptions, appeals and grievance processes work, please download the appropriate plan Evidence of Coverage chapters in the box at the top of the page to the right.

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, call Member Services at: 

Blue Shield 65 Plus, Blue Shield 65 Plus Choice Plan and Blue Shield Trio Medicare members:

(800) 776-4466 [TTY 711] between 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday) from April 1 through September 30.

Blue Shield Medicare Prescription Drug Plan members:

(888) 239-6469 [TTY 711] between 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday) from April 1 through September 30.

 

Exceptions Appeals and Grievances in Your Evidence of Coverage

Following are grievance forms for some Blue Shield Medicare health plans. For more details on exceptions, appeals and grievances, please refer to your plan’s Evidence of Coverage.

Blue Shield Medicare Advantage HMOs 

English (PDF, 540KB)
Spanish (PDF, 20KB)

Blue Shield Medicare Prescription Drug Plans

English (PDF, 452KB)
Spanish (PDF, 450KB)

 

Medicare Compliant form:

You can provide feedback directly to Medicare about your Medicare health or drug plan with the Medicare Complaint Form.

 

To view these PDF documents you'll need Adobe Reader.

This information is not a complete description of benefits. Contact Member Services at (800) 776-4466 [TTY: 711] for more information.