Appeals and Grievances Form
If you are a member of one of our plans for Medicare beneficiaries, you, your representative or prescriber may use the form below to file an appeal or grievance (complaint) request. Please provide any detailed information you feel may be helpful in supporting your request. Before submitting a request, please be sure to read about the details of our appeals and grievances processes by selecting this link.
You have the right to request an appeal when we have denied your request for coverage or payment of a prescription drug or medical benefit. A grievance is any complaint that does not involve and organizational determination for coverage or payment of medical or prescription drug benefits. Many complaint issues may be resolved by our Member Services department. You may want to contact Member Services for prompt resolution of your issue before submitting an online form. Please contact Member Services by using the telephone number listed on your Blue Shield member ID card or by using one of the specific plan contact numbers on the Exceptions & Appeals page.