Part 10 – Appeal and Grievance Program (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 88 of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Or, you may fax your request to 1-617-246-3616. Blue Cross Blue Shield HMO Blue will let you know that your request was received by sending you a written confirmation within 15 calendar days. When you send your request, you should be sure to include any documentation that will help the review.  To send an e-mail. You may send your request for an appeal or a grievance review to the Blue Cross Blue Shield HMO Blue Member Appeal and Grievance Program e-mail address [email protected]. Blue Cross Blue Shield HMO Blue will let you know that your request was received by sending you a confirmation immediately by e-mail. When you send your request, you should be sure to include any documentation that will help the review.  To make a telephone call. You may call the Blue Cross Blue Shield HMO Blue Member Appeal and Grievance Program at 1-800-472-2689. When your request is made by phone, Blue Cross Blue Shield HMO Blue will send you a written account of your request for an appeal or a grievance review within 48 hours of your phone call. Before you make an appeal or file a grievance, you should read “What to Include in an Appeal or Grievance Review Request” that shows later in this section. Once your appeal or grievance request is received, Blue Cross Blue Shield HMO Blue will research the case in detail. Blue Cross Blue Shield HMO Blue will ask for more information if it is needed and let you know in writing of the review decision or the outcome of the review. If your request for a review is about termination of your coverage for concurrent services that were previously approved by Blue Cross Blue Shield HMO Blue, the disputed coverage will continue until this review process is completed. This continuation of your coverage does not apply to services: that are limited by a day, dollar, or visit benefit limit and that exceed the benefit limit; that are non-covered services; or that were received prior to the time you requested the formal review. It also does not apply if your request for a review was not received on a timely basis, based on the course of the treatment. All requests for an appeal or a grievance review must be received by Blue Cross Blue Shield HMO Blue within 180 calendar days of the date of treatment, event, or circumstance which is the cause of your dispute or complaint, such as the date you were told of the service denial or claim denial. Office of Patient Protection The Massachusetts Office of Patient Protection can help members with information and reports about health plan appeals and complaints. To contact that office, you can call 1-800-436-7757. Or, you can fax a request to 1-617-624-5046. Or, you can go online and log on to the Office of Patient Protection’s Web site at www.mass.gov/hpc/opp. What to Include in an Appeal or Grievance Review Request Your request for an internal formal appeal or grievance review should include: the name, ID number, and daytime phone number of the member asking for the review; a description of the problem; all relevant dates; names of health care providers or administrative staff involved; and details of the attempt that has been made to resolve the problem.  Appealing a Coverage Decision. A “coverage decision” is a decision that Blue Cross Blue Shield HMO Blue makes about your coverage or about the amount Blue Cross Blue Shield HMO Blue will pay for your health care services or drugs. For example, your doctor may have to contact Blue Cross Blue Shield HMO Blue and ask for a coverage decision before you receive proposed services. Or, a coverage decision is made when Blue Cross Blue Shield HMO Blue decides what is covered and how