How Do I Appeal a Decision You Made About My Medicare Coverage?

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.

If you don't agree with our decision, you can appeal it. That's when you ask us to review your request again and change our decision. 

You can always talk to us about an appeal by calling the number on the back of your member ID card.

How long do I have to appeal a decision?

You have 60 days to contact us about an appeal after you get our written notification. 

We may give you more time in some cases to file an appeal, 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 you're waiting to receive, 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?

Your doctor should ask for a fast appeal. You or your representative can also 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.

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

The easiest way to start an appeal is by calling the number on the back of your member ID card. 

Or you can send us a letter or fax.

Don't have your Blue Cross ID card handy?

Here's another way to reach us by phone.

1-877-241-2583
TTY users call 711
8 a.m. to 8 p.m. ET
Monday through Friday

Mail or fax your medical coverage decision appeal

Describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, enrollee ID, a daytime telephone number and signature.

Blue Cross Blue Shield of Michigan
Grievance and Appeals Department
P.O. Box 2627
Detroit, MI 48231-2627

Fax: 1-877-348-2251

Don't have your Blue Cross ID card handy?

Here's another way to reach us by phone.

1-800-450-3680
TTY users call 711
8 a.m. to 8 p.m. ET
Monday through Friday

Mail or fax your medical coverage decision appeal

Describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, enrollee ID, a daytime telephone number and signature.

BCN Advantage
Grievance and Appeals Unit
P.O. Box 284
Southfield, MI 48086-5043

Fax: 1-866-522-7345

Email: BCNGrievance@bcbsm.com

How do I appeal a decision related to prescription drugs?

You can call the number on the back of your member ID card. 

Or you can fill out our online callback form and we’ll call when it’s convenient for you.

You can also write us a letter or send us a fax with your appeal. 

Don't have your Blue Cross ID card handy?

Here's another way to reach us by phone.

1-877-241-2583
TTY users call 711
8 a.m. to 8 p.m. ET
Monday through Friday

Fill out a form

You can ask us to review a decision we made related to prescription drugs using the Medicare Plus Blue PPO and Prescription Blue PDP Request for Redetermination Form (PDF).

Mail or fax your prescription coverage decision appeal

Describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, enrollee ID, a daytime telephone number and signature.

Blue Cross Blue Shield of Michigan
Clinical Pharmacy Help Desk — C303
P.O. Box 807
Southfield, MI 48037

Fax: 1-866-601-4428

Don't have your Blue Cross ID card handy?

Here's another way to reach us by phone.

1-800-450-3680
TTY users call 711
8 a.m. to 8 p.m. ET
Monday through Friday

Fill out a form

You can ask us to review a decision we made related to prescription drugs using the BCN Advantage HMO and HMO-POS Request for Redetermination Form (PDF).

Mail or fax your prescription coverage decision appeal

Describe what you would like to appeal and, if possible, include a copy of the letter you received from us. Include your name, enrollee ID, a daytime telephone number and signature.

BCN Advantage
Clinical Pharmacy Help Desk — C303
P.O. Box 807
Southfield, MI 48037

Fax: 1-800-459-8027

 

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