New tests, treatments, and medications hold the promise of improving or even saving lives.īut not all innovations create meaningful benefits, and not all care that is administered follows accepted standards for care. Aligning care with best practices: clinical appropriateness review We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services. Our mission is to help ensure delivery of health care services are more clinically appropriate, safer, and more affordable. You may also ask for a State Fair Hearing Appeal within 120 calendar days of the date on the Decision Notice.įor more information regarding Appeals and Grievances, please see your Member Handbook.About Carelon Medical Benefits ManagementĬarelon is a leading specialty benefits management company with more than 30 years of experience. If you disagree with the decision made on your appeal, you can ask for an External Review within 30 calendar days of the date on the Decision Notice. If you are hearing impaired, call the Illinois Relay at 711.Īfter you file an appeal, we will call to tell you our decision and send you and your authorized representative a Decision Notice. If you do not speak English, we can provide an interpreter at no cost to you. There are two ways to file an appeal or grievance (complaint):
Aim specialty health appeals how to#
Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services.Your right in some circumstances to ask for an expedited appeal and how to do it.Your right to ask for a State Fair Hearing and how to do it.Your right to file an appeal and how to do it.What action was taken and the reason for it.You must file your appeal within 60 calendar days from the date on the Notice of Action letter. If BCBSIL decides that a requested service cannot be approved, or if a service is reduced, stopped or ended, you will get a “Notice of Action” letter from us. Does not approve a service for you because it was not in our network.Does not answer your appeal in a timely manner.Does not give you the service in a timely manner.Does not pay for a service your PCP or other provider asked for.Stops a service that was approved before.Does not approve a service your provider asks for.You might want to file an appeal if BCBSIL: Your provider or a BCBSIL employee did not respect your cultural needs or other special needs you may haveĪn appeal is a way for you to ask for someone to review our actions.Your provider or a BCBSIL employee was rude to you.You were unhappy with the care or treatment you received.You had trouble getting an appointment with your provider in an reasonable amount of time.Your provider or a BCBSIL employee did not respect your rights.Filing a complaint will not change your health care services or your benefits coverage. We will do our best to answer your questions or help to meet your concern.
BCBSIL has special procedures in place to help members who file grievances. If you have a complaint about a provider or about the quality of care or services you have received, you should let us know right away. We want to know what is wrong so we can make our services better. Grievance (Complaint):Ī grievance is a complaint about any matter besides a service that has been denied, reduced or ended.īCBSIL takes member complaints very seriously. But if you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. At Blue Cross and Blue Shield of Illinois (BCSBIL), we take great pride in ensuring that you receive the care you need.
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