Part 10 – Appeal and Grievance Program (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 89 much you will pay for services you have already received. In some cases, Blue Cross Blue Shield HMO Blue might decide a service or drug is not covered or is no longer covered for you. You can make an appeal if you disagree with a coverage decision made by Blue Cross Blue Shield HMO Blue. When you make an appeal about a medical necessity coverage decision, Blue Cross Blue Shield HMO Blue will review your health plan contract and the policies and procedures that are in effect for your appeal along with medical treatment information that will help in the review. Some examples of the medical information that will help Blue Cross Blue Shield HMO Blue review your appeal may include: medical records related to your appeal, provider consultation and office notes, and related lab or other test results. If Blue Cross Blue Shield HMO Blue needs to review your medical records and you have not provided your consent, Blue Cross Blue Shield HMO Blue will promptly send you an authorization form to sign. You must return this signed form to Blue Cross Blue Shield HMO Blue. It will allow for the release of your medical records. You have the right to look at and get copies (free of charge) of records and criteria that Blue Cross Blue Shield HMO Blue has and that are relevant to your appeal, including the identity of any experts who were consulted. If you disagree with how your claim was paid or you are denied coverage for a specific health care service or drug, you can make an appeal about the coverage decision. Blue Cross Blue Shield HMO Blue will review the health plan contract that is in effect for your appeal to see if all of the rules were properly followed and to see if the service or drug is specifically excluded or limited by your health plan. The appeal decision will be based on the terms of your health plan contract. For example, if a service is excluded or limited by your health plan contract, no benefits can be provided even if the services are medically necessary for you. For this reason, you should be sure to review all parts of your health plan contract for any coverage limits and exclusions. These parts include your Subscriber Certificate and Schedule of Benefits and riders (if there are any) that apply for your health plan contract.  Filing a Grievance. You can file a grievance when you have a complaint about the care or service you received from Blue Cross Blue Shield HMO Blue or from a health care provider who participates in your health care network. Some examples of these types of problems are: you are unhappy with the quality of the care you have received; you are having trouble getting an appointment or waiting too long to get care; or you are unhappy with how the customer service representative has treated you. If you submit a formal grievance about the quality of care you received from a Blue Cross Blue Shield HMO Blue provider, Blue Cross Blue Shield HMO Blue will contact you to obtain your permission to contact the provider (if your permission is not included in your formal grievance). For this type of grievance, Blue Cross Blue Shield HMO Blue will investigate the grievance with your permission, but the results of any provider peer review are confidential. For this reason, you will not receive the results of this type of investigation. Choosing an Authorized Representative You may choose to have another person act on your behalf during the appeal or grievance review process. Except as described below, you must designate this person in writing to Blue Cross Blue Shield HMO Blue. If your claim is for urgent care or emergency medical care services, a health care professional who has knowledge about your medical condition may act as your authorized representative. In this case, you do not have to designate the health care professional in writing. If you are not able to designate another person to act on your behalf, then a conservator, a person with power of attorney, or a family member may act as your authorized representative. Or, they may appoint someone else to act as your authorized representative.