Navigating the healthcare system can sometimes be complex, especially when it comes to understanding your rights as a plan member in Tennessee. If you find yourself disagreeing with a decision made by your health plan regarding a claim, it’s important to know that you have options to appeal. This guide outlines the medical service appeals process available to you, ensuring you understand each step to advocate for your healthcare needs effectively.
Understanding the Appeals Process
Should you encounter an issue with a claim, payment, or processing, your first step is to reach out to member services. For BlueCross BlueShield of Tennessee members, you can call 800.558.6213. Cigna members can contact 800.997.1617. Often, a direct conversation can resolve misunderstandings and provide clarity on the situation.
First Level Appeal: Internal Review
If contacting member services doesn’t resolve your concern, the next step is to file a formal first-level appeal, also known as an internal review or member grievance. It’s crucial to adhere to the stated timeframes for filing these requests. Upon receiving your appeal, you will receive a notification outlining the process and expected timelines. Following a thorough review, you will be informed of the decision in writing, including details of any further appeal options available to you. This may include the possibility of an external review by an independent organization.
Second Level Appeal: Further Internal Review
In the event that your first-level appeal is denied, you have the option to file a second formal request for an internal review or member grievance. Similar to the first level, this request must be submitted within the specified timeframes. You will again receive acknowledgment of your request and be kept informed about the review process. The outcome of the second-level appeal will be communicated to you in writing, along with information regarding any subsequent appeal options, such as requesting an external review from an independent review organization.
External Review: Independent Assessment
For appeals denied at the internal levels due to medical necessity, you have the right to request an external review by an Independent Review Organization (IRO). This independent body will conduct a final assessment of your case and communicate their decision to you. The IRO’s decision is considered final and binding for all parties involved, including you, your health plan, and the carrier.
To initiate an appeal or grievance, you can find the necessary forms at: https://www.bcbst.com/members/tn_state/resources/ for BlueCross BlueShield of Tennessee, and https://stateoftn.cigna.com/ for Cigna. It’s important to note that members typically have 180 days from the date of an adverse decision notice to begin an internal appeal. Decision notifications are provided within specific timeframes:
- For urgently needed services: No later than 72 hours after appeal receipt.
- For denials of non-urgent care not yet received: Within 30 days.
- For denials of services already received: Within 60 days.
These timelines ensure a timely resolution to your appeals process, helping you get the healthcare services you need.
