Appeals
PW_006881
Note: The following appeals forms should only be used by, or on behalf of, an Anthem Blue Cross and Blue Shield of Maine member.
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 |
| 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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