How do I appeal a decision you made about my coverage?

Who is this for?

Learn more about how to appeal a coverage decision.

If you don’t agree with a decision we made about what your plan covers or how something is covered, including what you have to pay, this explains how to file an appeal.

Sometimes you, your doctor or your pharmacist may ask your plan to cover something it doesn’t already cover. Or you might ask us to cover a service or drug differently or change what we pay for it. When that happens, we have to make what’s called a coverage decision. When we notify you about our decision, you may not agree with it. What can you do?

You can appeal. That’s asking us to review your request again and change our decision. You can always talk to us about an appeal by calling the customer service number on the back of your Blues ID card.

Here’s an overview of what you need to know about appeals, and other ways to contact us about an appeal when you have a Medicare Advantage or a Prescription BlueSM PDP plan. You can find more information about appeals in your plan's Evidence of Coverage.

How long do I have to appeal a decision?

Medicare guidelines give you 60 days to contact us about an appeal after you get our written notification. We may give you more time in some cases, if you’re very ill, for example.

Who can appeal a decision?

You or your doctor can start an appeal. A representative—someone other than your doctor acting on your behalf—can also appeal a decision for you, as long as you fill out and send us an Appointment of Representative form. We won’t be able to complete the appeal process without it.

How long will it take to hear from us about an appeal?

It depends on what you’re appealing.

  • If your appeal is related to a medical service you're waiting to receive, we'll reply within 30 days.
  • If your appeal is related to prescription drugs, we'll reply within seven days.
  • If your appeal is related to payment for a medical service or drug you've already paid for, we'll reply within 30 days.
  • If your appeal is related to a medical service you've already received, or payment for a medical service you've already paid for, we'll reply within 60 days.

What if I can’t wait that long?

You can ask for a fast appeal when you’re appealing a decision about medical care or a prescription drug you haven’t received yet. If waiting could cause serious harm to your health or hurt your ability to function, you’ll hear from us within 72 hours.

Your doctor should request a fast appeal.

How do I appeal a decision related to a medical service or treatment?

It’s often easiest to call the customer service number on the back of your Blues ID card. If you’d rather start your appeal by filling out a form, writing a letter or sending a fax, you’ll find the contact information you need below.

How do I appeal a decision related to prescription drugs?

All members can:

  • Call the customer service number on the back of your Blues ID card.
  • Fill out our online callback form and we’ll call when it’s convenient for you.

If you’d rather write us a letter, send a fax or submit a form, the information you need is below.