You have certain rights guaranteed by federal law. If you have problems or concerns, you may make a formal complaint. There are specific guidelines set by the Medicare program about how you can make a complaint, how the complaint must be classified, and the timelines in which we must address and respond to your complaint.
You can call us to request a coverage determination by telephone, or you may submit the Coverage Determination form by fax or mail.
You will not be disenrolled from Medicare Plus BlueSM PPO or Prescription BlueSM PDP or penalized if you initiate a complaint. Your complaint will always be handled fairly and investigated within the guidelines of the Medicare program.
Contact Member Services first
Our Member Services representatives are here to assist you with any concerns, questions or problems you have with Medicare Plus Blue PPO or Prescription Blue PDP or care that you have received.
To reach Member Services, call the number on the back of your Medicare Plus Blue PPO or Prescription Blue PDP ID card.
If our Member Services department is not able to resolve your concern or your issue requires handling by our Grievance and Appeals Department, a Member Services representative will help you get started. Other information and links below may be helpful to you as well.
Member Services representatives can assist you with:
- Filing a complaint, or grievance, about service that you have received from Medicare Plus Blue PPO or Prescription Blue PDP, your pharmacy, physician, hospital, or other types of providers that have furnished services to you.
- Requesting a coverage decision, or organization determination, to find out if Medicare Plus Blue PPO or Prescription Blue PDP will cover the medical care or services you want.
- Understanding how to appeal a decision made by Medicare Plus Blue PPO or Prescription Blue PDP that you believe is incorrect or not in your favor.
Other helpful information
- Ending your membership
- Rights and responsibilities
- Appointment of Representative form
- Grievance — A type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of your care.
- Coverage determination (drug) — A decision we make about the prescription drug benefits you are entitled to get under the plan and the amount you are required to pay for a drug.
- Coverage decision (medical service or item) — A decision we make about the medical service or item you are entitled to get under the plan and the amount you are required to pay.
- Appeal — A type of complaint you make when you want us to reconsider and change a decision we have made about what drugs are covered for you or what we will pay for a drug.
- Exception — A type of coverage determination that, if approved, allows you to get a drug that is not on your plan's formulary, or get a non-preferred drug at the preferred cost-sharing level.
Note: To request a list of grievances, appeals and exceptions filed with us, please contact us.
Phone: 1-877-241-2583 (TTY: 711) from 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. Certain services available 24/7 through our automated telephone response system.
Blue Cross Blue Shield of Michigan
Grievance and Appeals Department
P.O. Box 2627
Detroit, MI 48231-2627
For process and status questions, members and providers can contact us at the numbers listed above.