Appeals and grievances
As a Blue Shield of California Medicare Advantage or Prescription Drug 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 it. 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. Your comments help us improve the services we provide to you.
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To check the status of a complaint you've already filed, and find information about what each status means, log in to your account to access your grievance status page.
There are two types of complaints you can make. The type of complaint you file depends on your situation.
The process for making an appeal with a Blue Shield of California Medicare plan
An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made. This can be 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, your prescribing doctor, or your appointed representative must send a written appeal request stating the nature of the complaint to the Blue Shield of California Medicare Appeals & Grievances department.
There are a few different types of decisions we can make regarding your appeal.
For plans with medical benefits:
- 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 standard decision about Part B 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.
For prescription drug plan:
- For a decision about payment for Part D prescription drugs you already received: After we receive your appeal, we have 14 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.
Requesting a fast appeal
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 must 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.
Making a decision on your appeal
We may extend the timeframe of your appeal by up to 14 calendar days if you request an 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 your Medicare coverage ends.
A 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:
- The quality of your care
- Waiting times for appointments
- The way your doctors or others behave
- Being able to reach someone by phone or get the information you need
- The cleanliness or condition of a doctor's office.
Our grievance process consists of two steps:
To begin the process, call a Customer Service 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:
Blue Shield of California
Medicare Appeals & Grievances
PO Box 927
Woodland Hills, CA 91365-9856
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 timeframe by up to 14 days if you ask for the extension. We may also extend the time 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 by calling:
(800) 776-4466 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round
Blue Shield Dual Special Needs Plans (D-SNP) members:
Blue Shield Balance (HMO) plan members:
(888) 802-4423 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round
Blue Shield Medicare Prescription Drug Plan members:
(888) 239-6469 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round
We will try to resolve your complaint over the phone. If you ask for a written response, we will respond in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.
If you are contacting us by fax or by mail, please download and complete a Blue Shield of California Appeals & Grievances Form
Blue Shield of California Medicare Appeals & Grievances
PO Box 927
Woodland Hills, CA 91365-9856
Fax: (916) 350-6510
Exceptions, appeals and grievances in your Evidence of Coverage
Following are grievance forms for Blue Shield Medicare Advantage plans. For more details on exceptions, appeals, and grievances, please refer to your plan’s Evidence of Coverage. See chapter nine for MAPD plans (PDF, 497 KB). See chapter seven for PDP plans (PDF, 314 KB).
Show all plan Evidence of Coverage documents
Medicare complaint forms
You can provide feedback directly to Medicare about your Medicare health or drug plan with the Medicare Complaint form.
To view PDF documents, you’ll need Adobe Reader.
This information is not a complete description of benefits. Contact Customer Service at the number on your member ID card for more information.
I'm not clear on my benefits. How can I learn more?
You can review your benefits through your online account. Go to blueshieldca.com/login to sign in or create your account. Once logged in, click on Benefits.
You can also call Customer Service at the number on your member ID card.
Can someone file an appeal or grievance for me?
If you would like someone to file a case for you, you can choose someone to represent you. For example, this could be a relative, friend, lawyer, or doctor. They can file appeals and grievances for you, and ask for authorizations for you. To make it legal, please fill out the Appointment of Representative form. Both you and your representative must sign it. Then return it to us at the address shown on the form.
For more information, view your Evidence of Coverage on our member resources page.
How long does it take to review my case?
The timing depends on your specific case. We want to do a thorough review. We may need to gather medical records, speak with your doctor, contact you, and/or consult with a specialist.
- For a grievance: We will send you a letter letting you know that we received the notice of your concern within five calendar days and give you the name of the person who is working on it. We will normally resolve it within 30 calendar days.
- For a standard appeal: We will give you our answer on a request for a medical item or service within 30 calendar days for pre-service (services you have not received yet) or 60 calendar days for post-service (for claims after you receive service) after we receive your appeal.
- For an expedited (fast) appeal: As long as your request meets the requirements of an expedited (fast) appeal, we will 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.
For more information, view your Evidence of Coverage on our member resources page.
What are the most common reasons for a denial?
The member may have used a service or requested an item that was not covered by the plan. The member may have had a treatment that was not deemed necessary or was not approved.
How do I get my appeal reviewed faster? Will calling help?
We can only do expedited (fast) reviews for appeals when there is an imminent and serious threat to the health of the member. This includes severe pain and potential loss of life.
Please do not call to check on the case. If you do so, you may delay the process by taking a representative away from the review.
However, if you have more information to provide for your case, we encourage you to call.
Can you email or call me instead of sending letters?
That depends on your specific situation. In some cases, we are required by law to send certain communications by mail. Whenever possible, we will honor your communication preferences.
What if my case is denied? What are my rights?
We want to be sure that you know your rights. That’s why each decision letter comes with information on what you can do next depending on your case.
I see organizations listed in the appeals letter. Who are they and what do they do?
We work with many organizations that oversee health care. Many of them have rules to be sure that the appeals process is fair. To learn more about them, please visit their websites listed on your appeals letter.
How can my appeal or grievance request be withdrawn?
The person who filed your request (you or your representative) needs to be the one to withdraw your appeal or grievance request. You or your representative can call the coordinator assigned to your case and let them know. Alternatively, you or your representative can let Customer Service know, and they will tell your case coordinator. To reach Customer Service, call the number on your member ID card.
Page last updated: 10/01/2023