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66 11/2005
Member Appeal Process
An integral part of BCBSGa’s continuous quality service improvement process is
identifying, tracking and improving member dissatisfaction issues. All members have
the right to voice dissatisfaction regarding UM/medical necessity decisions, health
plan processes and provider/practitioner interactions.
Customer concerns and inquiries may be directed to customer care at (800) 441-
CARE (2273) from 7 am until 7 pm, Monday through Friday.
Request for Information
Member dissatisfaction should not be confused with a member’s informal inquiry,
most often in the form of a question regarding coverage or status of a claim. Unless
resolved during initial interaction, customer care will respond within two (2) business
days of receipt of a general question or request for information. All other
inquiries/requests will be provided a response within twenty-one (21) calendar days.
Health Plan Process/Administrative Procedure
Complaints involving health plan processes or administrative procedures will be
acknowledged by member services within five (5) calendar days of receipt. These
complaints are responded to within thirty (30) calendar days or, forty-five (45)
calendar days if additional information is needed. If resolution cannot be determined
within the appropriate time frame, the member is notified of the delay. Notification
will be made within five (5) calendar days of the decision.
Utilization Management/Medical Necessity, Non-Covered Benefits and Formulary
Decisions
The member may appeal denied coverage for service related to utilization
management/medical necessity, non-covered benefit and formulary decisions. There
are two levels of appeal, which are described further below.