Resolving Problems for HMO Members

What is this about?

If you have a problem with your Blue Care Network service, this information explains what you can do to resolve it.

Blue Care Network and your primary care physician want you to be satisfied with the services you receive as a member. If you have a problem relating to your care, we encourage you to first discuss it with your PCP. Often your PCP can correct the situation to your satisfaction. Of course, you are always welcome to contact us with any questions or problems you may have. Just call the Customer Service number on the back of your enrollee ID card and we'll try to help.

In the event you are unable to resolve your concern through your PCP or Customer Service, we have established a formal grievance process. You have two years from the date of discovery of a problem to file a grievance with or appeal a decision of BCN. There are no fees or costs charged to you when filing a grievance. At any step of the grievance process, you may submit any written materials to help us in our review.

Step 1: Review and decision by BCN

To submit a grievance, you or someone authorized by you in writing must submit a written statement of the problem to our Appeals and Grievance Unit at the following address:

Appeals and Grievance Unit — Mail Code C248
Blue Care Network
P.O. Box 284
Southfield, Michigan 48086

The Appeals and Grievance Unit will review your grievance and give you a decision within 15 calendar days for preservice claims (claims that must be decided before a member is afforded access to health care) and within 20 calendar days for postservice claims (claims for a benefit involving the payment or reimbursement of the cost for medical care that has already been provided).

The person or persons who review this first-level appeal are not the same individuals who were involved in the initial determination. If an adverse determination is made, BCN will provide you with a written statement in plain English containing the reasons for the adverse determination, the next step of the grievance process and the forms to request the next grievance step. Upon request, we will provide, free of charge, all documents and records used to reach our determination.

If you are not satisfied with the determination, you may appeal to Step Two within 180 calendar days of receiving our determination. You, or a person authorized in writing to act for you, must notify the Appeals and Grievance Unit in writing at the address listed above of your decision to appeal. If you do not file a Step Two grievance within the 180-calendar day time frame, your grievance is considered abandoned and no further action may be taken.

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Step 2: Review and decision by BCN complaint panel

If you appeal from Step One, Blue Care Network's Step Two Member Grievance Panel will review and reconsider the determination made at Step One. You or someone authorized by you in writing may present the grievance in person or by telephone conference to the Step Two Member Grievance Panel.

For preservice claims (claims that must be decided before a member is afforded access to health care) and postservice claims (claims for a benefit involving the payment or reimbursement of the cost for medical care that has already been provided), notification of the Step Two grievance resolution will be sent to you within 15 calendar days of receiving your notice to appeal. If the grievance pertains to a clinical issue, the grievance will be forwarded to an independent medical consultant within the same or similar specialty for review. For postservice claims only, if BCN needs to request medical information, an additional ten business days will be added to the resolution time.

If an adverse determination is made, a written statement in plain English will be sent within five calendar days of the panel meeting, but not longer than 15 calendar days after receipt of the request for review. Written confirmation will contain the reasons for the adverse determination, the next step of the grievance process and the form to request an external grievance review. Upon request, we will provide, free of charge, all documents and records used to reach our determination.

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External complaint processes

If you do not agree with the decision at Step Two, you may appeal in writing to the State of Michigan insurance commissioner no later than 60 days following your receipt of our final determination at:

State of Michigan
Office of Financial and Insurance Regulation
Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720
1-877-999-6442

When filing a request for an external review, you will be required to authorize the release of any applicable medical records to the states that were used for review in reaching a decision.

If we fail to provide you with our final determination within 30 calendar days for preservice claims or 35 calendar days for postservice claims (plus ten additional business days if we request additional medical information) from the date we receive your written grievance, you may request an external review from the insurance commissioner. You must do so within 60 business days of the date you either received our final determination or the date our final determination was due. Mail your request for a standard external review, including the required forms that we will provide to you, to the Office of Financial and Insurance Regulation at the address noted above.

If you are a member of an ERISA*-qualified group, you may file a lawsuit according to the time limits defined in your General Provisions and Benefits booklet after completing our internal grievance process. You do not need to file an appeal with the insurance commissioner. Non-ERISA groups or nongroup subscribers, including their dependents, must exhaust all grievance steps (including an external review by the State of Michigan insurance commissioner) prior to filing a civil action. Subscribers may obtain further information from the local U.S. Department of Labor Office or by contacting the State of Michigan insurance commissioner. If you do not know if your group is an ERISA-qualified group, you should contact your employer.

*Employee Retirement Income Securities

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Expediting complaints

From Blue Care Network

You may request an expedited grievance when:

  • A physician provides verbal or written confirmation that you have a medical condition for which the time frame for completing a standard grievance would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function.
  • You believe that we have wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service, or you believe we have failed to respond timely to a request for benefits or payment.

Submit your request for an expedited grievance to us in writing by mail or by fax. Your physician must also confirm that your condition qualifies for an expedited grievance. Your physician's confirmation can be submitted in writing — by mail or by fax — or by telephone.

Mail or fax your request to:

Appeals and Grievance Unit — Mail Code C248
Blue Care Network
P.O. Box 284
Southfield, Michigan 48086
Telephone: 1-800-662-6667
Fax: 1-888-458-0716

We must provide our decision within 72 hours of receiving both your grievance and your physician's substantiation. If our decision is communicated to you verbally, we must provide a written confirmation within two business days.

If you do not agree with our decision, you may request an expedited external review from the Office of Financial and Insurance Regulation within ten calendar days of receiving our decision.

From the State

You may request an expedited external review from the State of Michigan when all three of the following conditions are satisfied:

  • A physician provides verbal or written confirmation that you have a medical condition for which the time frame for completing a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function.
  • You have filed a request with Blue Care Network for an expedited internal grievance. You do not have to wait for our final determination before you request an expedited external review.
  • You believe that we have wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service.

To request an expedited external review from the state, submit your request to the insurance commissioner at the same time you file your request for an expedited internal review with BCN or within ten calendar days of receiving our final determination. Your request can be made over the phone or in writing.

Office of Financial and Insurance Regulation
Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720
Toll-free telephone: 1-877-999-6442


*Employee Retirement Income Securities

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