Appeals and Grievances

Issues that can be appealed or grieved

Below is a summary of those issues that can be appealed or grieved through our member appeal and grievance process.
When BCBSAZ:

• Denies a request for preauthorization of a service not yet received
• Denies a claim for services already received
• Denies, reduces, or terminates the member’s plan benefits
• Fails to provide or pay for a benefit covered under the member’s plan
• Finds the member ineligible for a benefit under his or her plan
• Finds the member responsible for payment of cost share (copay, deductible, coinsurance, access fee, balance bill) for a plan benefit
• Finds that a service is not medically necessary
• Finds that a service is not covered because it is experimental or investigational
• Determines that the member is not eligible for coverage under the benefit plan
• Rescinds the member’s coverage under the plan

Authorization to represent
Laws and benefit plans vary regarding a provider’s right to initiate an appeal/grievance on behalf of a member. For most BCBSAZ plans, the following individuals are always authorized to appeal or grieve a decision and do not need any special authorization form:

• The treating provider acting on the member’s behalf
• A parent acting on the behalf of a minor

However, a few BCBSAZ plans for self-funded groups require specific member authorization before the provider can pursue an appeal for the member. In these cases, a provider who is appealing on a member’s behalf should use the Authorized Representative Designation Form to send us the patient’s authorization allowing the provider to receive appeal information on the patient’s behalf.

A provider initiating an appeal on behalf of a member should send the patient a copy of all information shared with us in connection with the appeal or grievance.

Note: Not all states allow providers to initiate an appeal/grievance on behalf of a member. For BlueCard® (out-of-area) members, be sure to check the member’s benefit book for appeal information.

Documentation to include when supporting a BCBSAZ member appeal/grievance
To enable us to timely and accurately respond to an appeal/grievance, providers should include the following information:

• A reference to the action or copy of the decision notice that is being appealed
• A written explanation of why the action may be incorrect, and the relief requested
• Documentation that disputed services meet the clinical criteria or pharmacy coverage guidelines
  • Clinical criteria are available on the azblue.com secure provider portal at “Practice Management > Medical Policies”
  • Pharmacy coverage guidelines are available at azblue.com/pharmacy
  • All other documentation that supports the appeal, such as medical records, operative reports, office notes

The provider and member are responsible for sending all relevant information to support a dispute and show why we should change our original decision. We do not solicit records to support an appeal/grievance. If the provider or member does not provide documentation, we will decide the appeal using only the information we already have.

BCBSAZ member appeal/grievance packets
We have a defined appeal/grievance process for members and their treating providers. However, some large, self-funded employer groups have benefit plans that require additional regulatory procedures and may have customized timelines and other protocols that deviate from the process used for most BCBSAZ members.

The specific dispute processes are explained in the appeal/grievance packet, which also includes all related forms. For most disputes, providers will use one of two “standard” appeals packets available below.

1. Standard Appeal/Grievance Packet 1 – for most BCBSAZ members
2. Standard Appeal/Grievance Packet 2 – for all self-funded employer groups, except those that have their own customized appeal packets, including:
   • State of Arizona (group # 30855; member ID prefixes SYD and S3Z)
   • Teamsters (group #s 31843 and 31844; member ID prefix TYW)
   • U-Haul (group # 026229; member ID prefix UHL)
   • IBEW (group # 038941)

For help in determining which appeal packet to use for a particular member, call the Medical Appeals and Grievance Department at 602-544-4938 or 1-866-595-5998.

Expedited Appeals
Expedited appeals require the treating provider to certify orally or in writing that the time periods required to process standard appeals could seriously jeopardize the member’s life, health, or ability to regain maximum function, cause a significant negative change in the member’s medical condition at issue, or subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

See the expedited appeal form below.

Exceptions to the Standard Appeal/Grievance Dispute Processes and Time Frames
The BCBSAZ standard member appeal/grievance dispute processes and time frames do not apply to:

• BlueCard^® members from other BCBS Plans, which have their own appeal procedures and time frames (some Plans have a 180-day window for submitting an appeal).
• Members with a self-insured group plan that customizes its appeal procedures (some use a 180-day time frame for submitting appeals).
• Enrollees in the Federal Employee Program^® (FEP^®) - Providers cannot appeal an FEP claim denial unless they are appealing on the member’s behalf with signed consent from the member. For details, refer to the member brochures online at fepblue.org. For provider disputes regarding adverse benefit determinations, refer to the provider dispute resolution processes below.
• Members with BCBSAZ Medicare Advantage (MA) plans – For information about MA member appeals/grievances, see the BCBSAZ Medicare Advantage Provider Operating Guide, Section 11 (in the secure provider portal under Provider Resources > Provider Operating Guide).
• Provider grievances - refer to the provider dispute resolution process below related to provider grievances or other administrative complaints.

We delegate responsibility for member appeals of some benefits to other vendors. Those vendors are also identified in the Standard Appeal/Grievance Packets below.

For more information about the BCBSAZ Member Appeals and Grievances Process, please refer to the Standard Appeal Packets below and the BCBSAZ Provider Operating Guide, Section 22.

Appointment of an authorized representative
To be appointed as an authorized representative for an MA member, both the member making the appointment and the representative accepting the appointment (including attorneys) must sign, date, and complete a representative form. Members may appoint a representative using the CMS Appointment of Representative form (CMS-1696), available from the CMS Forms List. Alternatively, a legal representative may be authorized by the court or, in accordance with state law, to act on behalf of a member. This type of appointment could include, but is not limited to, a court-appointed guardian, or an individual who has durable power of attorney for the member.

A signed Appointment of Representative form or other proof of legal representative status is required when a representative files a grievance or appeal on behalf of a BCBSAZ MA member. Per CMS guidance, a signed appointment form is valid for the grievance or appeal at hand for up to one year from the date the form is signed by both the member and the representative, unless the member indicates a shorter time frame, or revokes the appointment.

When an appointment of representative document is required, BCBSAZ will not begin a grievance or appeal review until or unless all appropriate documents are received. The time frame for processing a grievance or appeal request begins when we receive the appropriate documentation. If we don’t receive the appointment documentation or other requested documentation within a reasonable period of time, the grievance or appeal will be dismissed on the grounds that a valid request was not received.

MA MEMBER GRIEVANCES (complaints)
A member (or authorized representative) may file a grievance to convey the member’s dissatisfaction with BCBSAZ or a contracted provider, regardless of whether remedial actions are possible. Grievances may include concerns about:

• Operational issues such as long wait times, difficulty getting through to the health plan or a provider on the phone
• Benefits package
• Access to care
• Customer service
• Quality of care
• Interpersonal aspects of care (e.g., the demeanor of healthcare personnel or rudeness or disrespect to members)
• Adequacy of facilities

Filing an MA member grievance
An MA member (or authorized representative) may file a grievance orally or in writing within 60 calendar days after the date the event occurred. A grievance must include a complete description of the issue including details such as date and time of the event causing the member’s dissatisfaction, the location of the event, the name(s) of the people (e.g., service provider, employee, or agent) who were involved in or witnessed the event, and what circumstances caused the dissatisfaction (e.g., concerns regarding access to services, the quality of care, benefit package, aspects of health plan or provider operations or staff).

A member (or authorized representative) can call or send a written grievance to the BCBSAZ MA Grievance and Appeals Department at:
BCBSAZ Medicare Advantage Grievance and Appeals Department
P.O. Box 29234
Phoenix, AZ 85038-9234
Phone: 1-800-446-8331 (TTY 711)
Fax: 602-544-5656

All grievance requests are acknowledged in writing to the member (or authorized representative).

MA member grievance review process
The MA Grievance and Appeals Department conducts an investigation concerning the member’s grievance. During this process, we will contact any providers or departments related to the member’s grievance, address the grievance as quickly as possible, and respond to the member (or authorized representative) verbally or in writing no later than 30 calendar days after receiving the grievance. We may extend the time frame by up to 14 calendar days if the member requests an extension or if we justify a need for additional time and the delay is in the member’s best interest. If the member has filed an expedited grievance (based on CMS criteria), we will respond to the member (or authorized representative) within 24 hours.

Providers must comply with BCBSAZ investigation efforts in a timely manner so that the CMS timelines for processing member grievances can be met.

MA MEMBER APPEALS (requests for reconsideration)
A member (or authorized representative) has the right to file an appeal to request reconsideration of an adverse decision made by BCBSAZ. Appeals may be filed about:

• A decision to deny or delay in providing, arranging for, or approving healthcare services
• A dispute about the amount the member paid or is billed

Member appeal procedures include reconsideration/redetermination by BCBSAZ and may also include, under certain escalated circumstances, reconsideration by an independent review entity (IRE), a hearing before administrative law judges (ALJs), review by the Medicare Appeals Council, and a judicial review.

Filing an MA member appeal
According to CMS guidance, an MA member (or authorized representative) may file an appeal orally or in writing within 60 calendar days from the date of a denial notice. If the appeal is filed beyond the 60 calendar-day time frame and good cause is not provided, we will dismiss the case. All member appeals (requests for reconsideration/redetermination) are acknowledged in writing to the member and the authorized representative; or directly to the legal representative.

An appeal should include an explanation of why the original decision should be reconsidered, along with relevant documents, such as a copy of the adverse organization determination (denial), medical records, and any other documentation that support the appeal.

A member (or authorized representative) can call or send a written request for appeal/reconsideration to the BCBSAZ MA Grievance and Appeals Department at:

BCBSAZ Medicare Advantage Grievance and Appeals Department
P.O. Box 29234
Phoenix, AZ 85038-9234
Phone: 1-800-446-8331 (TTY 711)
Fax (Pre-service Part C & D Appeals): 602-544-5655
Fax (Standard Part C Claim Appeals): 602-544-5656
Fax (Standard Part D Claim Appeals): 602-544-5657

Typical review process for MA member Part C appeals
BCBSAZ has 30 calendar days to process a standard appeal for medical services that have not yet been provided, and 60 calendar days to process an appeal for reimbursement/payment for services that have already been provided. As part of this process, we will make every effort to obtain all necessary medical records and other information before making a decision. The member (or authorized representative) will be notified in writing of the decision and any additional rights available within the allowed time frame.

If the member, the member’s representative, or a treating provider requests an expedited appeal for medical services not yet provided, we will make a decision within 72 hours of the request. In certain situations, if it is in the member’s best interest, an extension of up to 14 days may be taken. The member (or authorized representative) will be notified orally of the decision, followed by a written notice within three calendar days of the oral notice. If the expedited appeal request does not meet criteria to be processed as expedited, it will be changed to a standard appeal time frame. The member (or authorized representative) will be notified in writing of this change and of the right to file an expedited grievance about the decision.

Review process for standard MA pre-service appeals related to Part D prescription drugs
BCBSAZ has seven calendar days to process a request for a standard pre-service redetermination regarding Part B and D prescription drugs. During this process, we will make every effort to obtain all necessary records and other information before making a decision. The member (or authorized representative) will be notified in writing of the decision and any additional appeal rights within the allowed time frame.

If BCBSAZ approves a request to expedite a redetermination of a Part D prescription drug, a decision will be made within 72 hours of the request. The member (or authorized representative) will be notified in writing of the final decision. If a request to expedite a redetermination does not indicate that the member’s life, health, or ability to regain maximum function could be jeopardized, we may transfer the request to the standard redetermination process. The member (or authorized representative) will be notified in writing within three calendar days of the decision to apply the standard redetermination process and the right to file an expedited grievance about the decision.

1. Credentialing Disputes - resolution process

a. Terminations for professional competency, conduct or quality of care
Contracted providers may dispute BCBSAZ's decision to terminate a contract for lack of professional competence or for professional misconduct. Examples of these disputes include, but are not limited to:

• Belief that a quality-of-care issues exists
• Adverse action taken by a hospital
• Disciplinary action taken by a licensing board
• Trend or pattern of quality-of-care issues

If a provider is terminated for professional competency or conduct:

1. BCBSAZ will notify the provider in writing of the reason for the termination and of the provider’s reconsideration rights.


2. The provider may request reconsideration in writing (including relevant information) no later than 30 calendar days after receipt of notice of termination from BCBSAZ.
   1. A reconsideration panel consisting of at least three qualified individuals who did not participate in the original decision, with at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees, will review the reconsideration request at its next meeting (scheduled at least quarterly).
   2. The panel will notify the provider within seven calendar days of its decision.
3. If the provider is not satisfied with the panel's decision, the provider has 30 calendar days from the receipt of the decision to request a second-level reconsideration (with a personal appearance before a second panel).
   1. A second panel of three individuals who did not participate in the first-level decision, including at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees, will hold the second-level reconsideration hearing. The panel will be convened no later than 60 calendar days after BCBSAZ receives the provider’s request unless an extension is necessary (for up to an additional 60 calendar days).
   2. The panel's decision is final and will be communicated to the provider in writing, via certified mail, within seven calendar days of the decision.

b. Immediate suspension or termination related to concerns for member safety
If a BCBSAZ medical director believes a provider is practicing in a manner that poses a significant risk to the health, welfare, or safety of members, BCBSAZ can either immediately suspend or terminate the provider.

• If the circumstances require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately suspend the provider contract and conduct an expedited investigation.
• If the circumstances do not require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately terminate the provider contract.
• Examples of circumstances that might result in immediate suspension or termination include, but are not limited to:

• Insufficient or no professional liability insurance
• Sanction by Medicare/Medicaid
• Exclusion from any federal programs
• A change in license status which prohibits the provider from practicing or places limitations that materially limit the provider’s ability to provide a full range of medically necessary services to members
• Fraudulent activity

When a suspension or termination occurs:

1. BCBSAZ will promptly remove the provider from the directory and send the provider written notice of the action and the reason for it.


2. The provider has 30 calendar days from receipt of the notice to send BCBSAZ a written request for reconsideration if the triggering event allows for reconsideration rights (certain types of felony convictions cannot be appealed). The request should include relevant information.
1. A reconsideration panel will review the reconsideration request at its next meeting (scheduled at least quarterly). The panel will have at least three qualified individuals who did not participate in the original decision, with at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees.
2. The panel will notify the provider of its decision within seven calendar days after the meeting.
3. If the provider is not satisfied with the panel's decision, the provider has 30 calendar days from receipt of the decision to request a second-level reconsideration (with a personal appearance before a second panel).
1. A personal appearance panel will hold a second-level reconsideration hearing no later than 60 calendar days after BCBSAZ receipt of the request. The panel may extend the time period for up to an additional 60 calendar days, for good cause. (The panel will have three individuals, who did not participate in the first-level decision, including at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees).
2. The panel's decision is final and will be communicated to the provider in writing, via certified mail, within seven calendar days of the decision.

2. Administrative Disputes - resolution process

Administrative disputes are different from disputes related to professional competence or conduct, or quality of care. There are two types of administrative disputes:

1. Provider contract breach initiated when BCBSAZ notifies a provider that the provider is in breach of the network participation agreement or a policy incorporated in the agreement: and
2. Provider grievance initiated by a provider due to disagreement or dispute with BCBSAZ. 

a. Provider contract breaches
A contract breach dispute can arise when a contracted provider wishes to protest BCBSAZ’s decision that the provider is in breach of obligations in the provider’s participation agreement or a BCBSAZ policy that is incorporated by reference in the provider’s agreement. Examples of provider contract breach disputes include, but are not limited to:

• Non-compliance with administrative terms in the network participation agreement or Provider Operating Guide
• Billing a member in violation of the member hold harmless provisions of the agreement
• Failure to timely submit requested medical records
• Referrals to providers and use of facilities outside the member's network when network providers and facilities are available

BCBSAZ will take appropriate action to address any breach of contract. If the provider does not cure the breach following notice from BCBSAZ, it may result in contract termination.

If BCBSAZ invokes the contractual right to terminate a provider’s contract, we will initiate the administrative dispute process as described below.

Contract breach dispute resolution process

1. BCBSAZ will send a termination letter to notify the provider that the contract is terminated and provide information about the dispute resolution process and reconsideration rights.
2. The provider may request reconsideration in writing (including relevant information) no later than 30 calendar days after receipt of the notice from BCBSAZ.
3. After the provider’s reconsideration request is received, an authorized representative who was not involved in the initial decision on the subject of the dispute will review the written request for reconsideration and make a decision.
4. The authorized representative's decision is final and will be communicated to the provider in writing within 30 calendar days of receipt of the provider's written reconsideration request.

b. Provider grievances 

BCBSAZ supports three types of provider grievance processes. Only one process may be used to resolve a dispute.

1. Disputes related to Medicare Advantage (MA) claim payments
   These disputes are handled through the MA claim reconsideration process.


2. Disputes related to the initial payment for commercial and FEP claims in-scope for the No Surprises Act (NSA) negotiation/arbitration process, including:
   • Out-of-network emergency services
   • Air ambulance services
   • Non-emergency services rendered by out-of-network providers in an in-network facility

   These disputes are resolved through the NSA negotiation/arbitration process. To the extent that BCBSAZ is required by A.R.S. § 20-3102(F) to have a process for resolving payment disputes, BCBSAZ has adopted the NSA process for all claims considered in-scope for the NSA as listed above. A non-participating provider may initiate the 30-day open negotiation process by submitting the NSA Claim Payment Negotiation Request form along with a copy of the remit statement. Any dispute that is not settled within the 30-day period may be referred to an independent federal arbitrator. For more information and forms, visit azblue.com/NoSurprises.

3. Disputes related to all other types of BCBSAZ payment and administrative issues (this process is available to contracted and non-contracted providers)

These disputes are resolved through the BCBSAZ grievance process in compliance with Arizona state law (A.R.S. §§ 20-3101 and 20-3102).

Please note: Provider grievances arising out of services rendered to Federal Employee Program® (FEP®) members are not within the scope of the state law regarding provider grievances. However, FEP does afford providers an independent right to grieve as outlined here. FEP refers to the provider grievance process as provider “appeals” or “reconsiderations.”

Contracted and non-contracted providers may initiate the process by sending BCBSAZ a written request (see optional provider grievance form below at Provider Dispute Forms).
Grievance issues may include but are not limited to:

• Whether a claim was clean
• Timely filing
• Failure to timely pay a claim
• Amount paid (bundling software)
• Amount paid (other than bundling software); Amount paid (other than bundling software)
• Amount or timeliness of interest payment
• Adjustment request
• Denials that require a provider write-off (for example: investigational/experimental)
• Network adequacy (other than the provider's contract status)
• Systemic or operational problems
• COB issues
• Coinsurance/deductible
• Sanction deductible
• Fee schedule disputes
• Outpatient global pricing
• DRG payment
• Fragmentation of incidental procedures
• Modifiers
• Multiple medical/surgical procedure processing
• Mutually exclusive procedures
• Procedure unbundling

No claim corrections are permitted after a grievance is filed 
Before submitting a grievance related to a claim, ensure that all information on the claim is accurate. A claim may not be corrected after a grievance has been filed. Grievance decisions are based on the premise that all information on the claim is accurate.

BCBSAZ provider grievance process: First-level review
All grievances must be in writing and submitted to BCBSAZ no later than one year after the denial or other notification, or date of the occurrence if the provider did not receive notification. BCBSAZ may extend this one-year time period for good cause or if a longer period is required by state or federal law. "Good cause," as used in here, means circumstances that were beyond the reasonable control of the provider and that prevented the provider from submitting a timely grievance request.

1. The provider sends a first-level grievance request to BCBSAZ within the time frame explained above, including:
   • A reference to, or copy of, the action with which the provider disagrees
   • A written explanation of why the provider thinks the action is wrong, and the relief the provider is requesting
   • All necessary documentation that supports the provider's position, such as medical records, operative reports, or office notes
2. BCBSAZ employees who were not involved in the initial determination review the grievance, including any new information submitted to BCBSAZ.


3. BCBSAZ sends the provider written notice of the grievance decision within 60 calendar days of receipt.

BCBSAZ may extend the 60-day time period for up to an additional 60 calendar days. If we require an extension, we will notify the provider in writing before the initial time period expires.

BCBSAZ will mail all decisions to the provider's last address on file, except for providers located outside of Arizona. We transmit decisions for out-of-state providers to the BCBS Plan in the provider's home state, and that BCBS Plan sends the decision to the provider. The decision is deemed received on the date of delivery, if hand delivered, or, if mailed, on the earlier of the actual date of receipt or five days after deposit in the U.S. mail, postage prepaid.

BCBSAZ provider grievance process: Second-level review
If the provider is dissatisfied with BCBSAZ's first-level grievance resolution, a second-level grievance may be requested. The second-level grievance must be submitted in writing to BCBSAZ within 60 calendar days after receipt of the first-level grievance determination. A provider may extend the 60-day time period for up to an additional 60 calendar days. If the provider requires this additional time to submit the second-level grievance, the provider must notify BCBSAZ in writing within the initial 60-day period.

1. The provider sends the second-level grievance request to BCBSAZ within the time frame explained above, including:
• A written explanation of the reason for dissatisfaction with the prior decision
• Any new supporting information for review
2. BCBSAZ notifies the provider of the final decision within 60 calendar days after BCBSAZ receives the provider's second-level grievance request.

BCBSAZ may extend this 60-day time period for up to 30 calendar days on written notice to the provider, to be given within the 60-day period.

Send BCBSAZ provider grievances and all necessary documentation to:

BCBSAZ Appeals and Grievances Department - Mailstop A116
P.O. Box 13466
Phoenix, AZ 85002-3466 

For grievances related to:

• FEP claims or issues, use Mailstop B205
• BlueCard® (out-of-area members) claims or issues: use Mailstop T201.
• CHS group claims or issues: send the grievance and documentation to the group’s third-party administrator (TPA) at the address listed on the remittance advice.
• Chiropractic claims or issues: see information below.

Other information regarding BCBSAZ provider grievances

• Situations not applicable to the grievance process
  These provider grievance process does not apply to denial of admission to the BCBSAZ network, termination from the network, or a complaint that is the subject of a member appeal under A.R.S.§ 20-2530.


• Appeals and grievances for members
  The provider grievance process is distinct from the member appeal and grievance process and is not meant to limit provider participation in the member appeal process. Providers who are authorized to act on behalf of a member may submit an appeal to BCBSAZ as permitted under the member appeal process and applicable federal law. For more information about member appeals, see Representing Member Appeals above and to the Provider Operating Guide, Section 23.


• Record requests
  BCBSAZ does not request records to support a grievance. Decisions are made on the basis of the information submitted with the grievance request, in combination with records previously received.



• Delegated entities
  BCBSAZ may delegate responsibility for handling grievances for certain delegated services to the vendors involved in administering those services:

Chiropractic services administered by American Specialty Health (ASH)
Chiropractic services are administered by ASH for most BCBSAZ plans (see exceptions below), including administration of the dispute resolution process. Direct disputes to:

American Specialty Health (ASH), Attn: Appeals Coordinator
P.O. Box 509001
San Diego, CA 92150-9001
Phone 1-800-972-4226  |  Fax 1-877-248-2746

Exceptions:

• For disputes regarding chiropractic services (and related claims) for members of customized large group plans for which ASH is not the designated administrator, direct the dispute to BCBSAZ.
• For disputes regarding chiropractic services (and related claims) for FEP members, direct the dispute to FEP.
• For disputes regarding chiropractic services (and related claims) for out-of-area BlueCard members, direct the dispute to BCBSAZ.
• For disputes regarding chiropractic services (and related claims) for CHS group members, direct the dispute to the third-party administrator (TPA).

• CHS group member appeals or provider disputes
  For CHS group members, direct all member appeals/grievances and provider grievances to the TPA at the address listed on the remittance advice. If the provider grievance is related to a specific pricing issue, the TPA will forward the grievance to BCBSAZ to review and determine if an adjustment needs to be made. If so, BCBSAZ will send the TPA a re-priced claim.