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Appeals

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Note: The following appeals forms should only be used by, or on behalf of, an Anthem Blue Cross and Blue Shield of Maine member.  
First Level Appeal Form
How to Appeal Our Determination - Second Level
Second Level Appeal Form
Independent External Review of a Denied Claim
 
If you are dissatisfied with the recent determination we issued, you can file an appeal. You must file an appeal within 180 days of the date we issued the adverse determination you are appealing. We are committed to responding to your concerns promptly and confidentially. An appeal of a medical necessity determination may be handled in an expedited manner if you, or your health care provider, believes that your condition would seriously jeopardize your life, health, or ability to regain maximum functioning by waiting for the appeal to be resolved using standard appeal time frames. An expedited appeal may be initiated by the covered person or the provider acting on behalf of the covered person. If you would like to request an expedited appeal, please call 1-800-392-1016.  
Who may appeal on your behalf?
You, your practitioner, or any other authorized representative you choose may appeal on your behalf. If you designate a representative, please provide that representative with a signed authorization to include with the appeal.  
What should your appeal include?
Identify (by patient name, certificate or identification number, provider of care, date of service, and, if available, by claim number) the specific determination with which you disagree. Explain the specific reason(s) why you do not agree with our determination. Please include all pertinent information regarding the care under appeal, especially any additional supporting documentation you would like us to review.  
How do you file an appeal?
In writing to our Appeal Analyst, PO Box 218, North Haven, CT 06473-0218
By telephone by calling our customer service representatives using the telephone number on the back of your health plan ID card
By e-mail using our secure online form
In person by visiting our South Portland headquarters or our local office in Augusta
 
How will your appeal be handled?
Our appeal analyst, along with appropriate administrative or clinical specialists, if necessary, will review the entire record of your appeal, including any additional supporting documentation you submit with your appeal, and will research and respond to the issues you have raised. If we need additional documentation, please be advised that your healthcare providers may require your signed authorization before they release medical records. We will issue a written decision within 20 working days of receiving your request for appeal.  
If you disagree with the determination on your appeal, can you appeal further?
Along with our determination, we will provide you with information on how to appeal further, and other rights available to you. If we deny your appeal and our determination is based on medical necessity, a pre-existing condition, or regarding an experimental or investigational service, you may have the right to request an external review by an Independent Review Organization. See the enclosed document for information regarding that process. Once you have completed at least one level of appeal, you may have a right to bring a civil suit, pursuant to Section 502 (a) of ERISA, against the plan for the benefit. Your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what might be available is for you to contact your plan, the local U.S. Department of Labor Office, or the State Bureau of Insurance (the Bureau) at 1-800-300-5000 or in writing at State House Station 34, Augusta, ME, 04333. You have the right to file a written or verbal complaint with the Bureau of Insurance at any time. The Bureau's Web site (www.state.me.us/pfr/ins/ins_consumer_info.htm) has more information.  
 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use