How to Appeal Our Determination - Second Level
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 disagree with our determination on your recent appeal, you, your practitioner, or any other authorized representative you choose, may wish to file an additional appeal. Your second level appeal must be received within 180 days of the date we issued our determination on your first level appeal. The second level of appeal is not required by Anthem before you initiate further action. However, we are committed to responding to your concerns promptly and confidentially and welcome the opportunity to conduct a second level review for you.
How do you file a second level appeal?
You may use our secure online second-level appeal form
or send a letter to:
| Anthem Blue Cross and Blue Shield, Level Two Appeals Analyst,|
PO Box 218, North Haven, CT 06473-0218
Although we recommend your appeal be submitted in writing, we will also accept it orally at the telephone number on the back of your health plan ID card. You may also visit our website, www.anthem.com and follow the instructions for filing an appeal, or in person at our South Portland headquarters or our local office in Augusta. Call us or visit our website to obtain directions to any of our offices.
How will your appeal be handled?
| Our appeals analyst will review the entire record of your appeal, research the issues you have raised, appoint and chair a panel of representatives not previously involved with the initial determination or the first level appeal. Clinical issues will be reviewed by an appropriate medical professional with demonstrable expertise to review the case.|
| If you wish, you will have the opportunity to appear before, and present your case to, the review panel. You can do this in person at our South Portland headquarters or through other means, such as a conference call. If you wish to appear before the review panel, you should include that information with your initial second level appeal request. We will notify you in writing of the date, time, and location of the panel meeting at least 15 days before the meeting.|
| You may authorize a representative, in writing, to assist or represent you at the review panel meeting.|
| You may submit any supporting material in advance of, or at, the review panel meeting. At the time of the review meeting, you may also ask questions of any of our representatives. In order to assure that a specific representative is available to participate in the review panel meeting, in person or by telephone conference, please provide the name of the representative, or whatever information you have which would identify the representative (ie; the date you spoke with or met with the representative) at the time you request the second level appeal.|
| We will make a determination within 45 working days of receiving your request for an appeal. Written notification will be issued within 5 working days of the appeal panel’s determination.|
If you disagree with the determination on your appeal, can you appeal further?
If we deny your appeal and our determination is based on medical necessity, a pre-existing condition, or regarding experimental or investigational service, you may have the right to request an external review by an Independent Review Organization. See the external review page
for information regarding that process. Unless you have the right to request an external review, our determination on your second level appeal is final. You cannot appeal further.
| The member is entitled to receive upon request and free of charge, reasonable access to, and copies of any documents, records, and other information relevant to the member’s claim for benefits.|
| If an internal rule, or similar criterion is relied upon in making the adverse determination, the specific rule, guideline, protocol, or other similar criterion will be provided to the member free of charge upon request.|
| If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination applying the terms of the plan to the member’s medical circumstances will be provided free of charge upon request.|
| The information above may be requested by calling the Customer Service number on the member’s identification card.|
| The member or the member’s authorized representative may contact the Bureau of Insurance at any time for assistance by writing to the Bureau of Insurance at 34 State House Station, Augusta, ME 04333-0034 or by calling (800) 300-5000. The Bureau of Insurance's Web site (www.state.me.us/pfr/ins/ins_consumer_info.htm) has more information.|
What other options are available to you?
Once you have completed at least one level of appeal, you may have the right to bring a civil action under Section 502 (a) of ERISA, against the plan for the benefit. You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact the local U.S. Department of Labor Office and the State insurance regulatory agency.