How can I resolve a problem with my PPO or EPO claim?
Who is this for?
If you have a PPO or EPO plan and are having a problem with your claim, this information explains how to report it to us.
It’s important to us that you’re satisfied with the way a claim or request for benefits is handled. If you have a preferred provider organization (PPO) or exclusive provider organization (EPO) plan, we can help clear up any issues you've had getting your claim processed.
If you have a problem, please call us first.
Use the phone number on the back of your Blues ID card, or in the top right hand corner of your Explanation of Benefit (EOB) statement. We’ll do our best to help.
I talked to Customer Service, and I still have a problem. Now what?
We have a formal grievance and appeals process you can follow. It doesn’t cost you anything to file a grievance or appeal a decision.
Use the state process if you:
- Are insured through your employer (including non-ERISA groups)
- Buy your own insurance
You can begin this process up to two years from when the problem started.
If you’re insured through a self-funded ERISA group, you’ll use the federal process. You can begin this process up to 180 days after you get a notice from us that denies or reduces payment on a claim.
Getting help fast: expedited grievance and review
There are occasions when we can speed up the grievance and appeals process. For example, we can move things along faster if waiting would jeopardize your life or health. Choose one of the processes below. Use the same process you'd use to file a standard grievance or appeal.