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Pre-service appeals

Federal process

For members who must get approval before obtaining certain health services


If your health plan requires you to get approval before obtaining certain health services, and you disagree with our decision not to approve a service, you have the right to appeal it.


Please follow the steps below to request a review. If you have questions or need help with the appeal process, please call the customer service number on the back of your Blues ID card.


All appeals must be requested in writing. We must receive your written request within 180 days of the date you received notice that the service was not approved.


To request a standard review

You may make the request yourself, or your doctor or someone else acting on your behalf may make the request for you. If another person will represent you, that person must obtain written authorization to do so. Please call the customer service number on the back of your Blues ID and ask for a Designation of Authorized Representative and Release of Information form. Complete it and send it with your appeal.

Your letter requesting a review must include the following information:

  • Your contract and group numbers, found on your Blues ID card
  • A daytime phone number for both you and your representative
  • The patient's name if different from the member
  • A statement explaining why you disagree with our decision and any additional supporting information

Once we receive your appeal, we will provide you with our final decision within 30 days.


To request an urgent review

If your situation meets the definition of urgent under the law, your review will be conducted generally within 72 hours. An urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. If you believe your situation is urgent, you may request an urgent review. You may also request a simultaneous external review.


For more information on how to request an urgent review or simultaneous external review, call the customer service number listed on the back of your Blues ID card.


For more information

At your request and without charge, we will send you details from your health care plan if our decision was based on your benefits. If our decision was based on medical guidelines, we will provide you with the appropriate protocols and treatment criteria. If we involved a medical expert in making this decision, we will provide that person's credentials.


To request information about your plan or the medical guidelines used, or if you need help with the appeal process, call the customer service number on the back of your Blues ID card.


Other resources to help you

For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). There is also a state agency available to assist you with any additional questions. You can contact the Office of Financial and Insurance


Mail or fax your written appeal to one of the following:
If your appeal is regarding specified organ or bone marrow transplants:   If your appeal is regarding an inpatient admission to a hospital, skilled nursing facility, or acute rehabilitation facility:

    Human Organ Transplant Program

    Blue Cross Blue Shield of Michigan

    600 E. Lafayette

    Mail Code 504C

    Detroit, MI 48226


    Fax: 1-866-752-5769

 

    Precertification Medical Records and Appeals

    Blue Cross Blue Shield of Michigan

    P.O. Box 321095

    Mail Code 511B

    Detroit, MI 48232-1095


    Fax : 1-877- 261-4555

     
     
If your appeal is regarding case management services:   If your appeal is regarding a prescription drug:

    Case Management Program

    Blue Cross Blue Shield of Michigan

    600 E. Lafayette

    Mail Code 504A

    Detroit, MI 48226-2998


    Fax: 1-866-643-7057

 

    Pharmacy Services

    Blue Cross Blue Shield of Michigan

    Pharmacy Services

    P. O. Box 2320

    Detroit, MI 48231-232


    Fax: 1-866-601-4425


Regulation's Michigan Health Insurance Consumer Assistance Program at 1-877-999-6442. For general information, visit michigan.gov/ofir.