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Complaints and Appeals

PW_006961
Please note:  

Federal Blue HMO members should refer to their benefit brochure under Disputed Claims Process.

The benefits information contained in these Frequently Asked Questions is for general information only. For more specific benefits information please consult your certificate of coverage or other plan documents.

What is the procedure for filing a complaint or appeal with Anthem?
Check your contract or Certificate to determine whether there is a specific process to follow. In order to help ensure that members' rights are protected, all Anthem members are entitled to the complaint and appeal process. Complaints include any expression of dissatisfaction regarding Anthem's services, products, network provider or employees. Appeals refer to formal requests by the member (or his/her legal representative) to change a decision previously made by Anthem regarding the refusal to arrange for or pay for certain services. Procedures for registering complaints and appeals are outlined in your certificate of coverage. 
Complaints 
When Anthem's Member Services receive oral or written complaints, we log it into the tracking system, research the issue and respond to the member. Anthem monitors its Member Services to promote the timely resolution of member complaints. 
Appeals 
If a complaint is not resolved to the member's satisfaction, the member may initiate a formal appeal by contacting Anthem Member Services. The Appeals Unit then reviews all supporting documentation, with assistance from medical and/or network management if necessary. Anthem then determines whether to reverse or uphold the original decision. Following the determination, Anthem sends the member a notification of its decision. Members are advised of additional steps available to them. If a member is not satisfied with the initial appeal determination, he/she may request an additional review by an appeals panel. Members are allowed a personal appearance before the appeals panel or may participate by phone. For certain issues, an External Appeal is also available to the member when the internal appeals process is exhausted without resolution to the member's satisfaction. 
At any time during the Complaint and Appeal Processes, issues involving urgently needed clinical care may be handled more quickly through an Expedited Appeal Process. 
Note: If your benefits are self-funded by your employer, your appeal procedure may be different in some respects from the procedure described here. You may call the member services number on your ID card if you would like more information. 
Due to statutory regulations, Kentucky members generally receive a single level of internal appeal, which can be a panel review for Kentucky HMO and POS. 
What is the procedure for lodging a complaint against a provider?
Check your contract or Certificate to determine whether there is a specific process to follow. In order to help ensure that members' rights are protected, all Anthem members are entitled to the complaint and appeal process. Complaints include any expression of dissatisfaction regarding Anthem's network providers. When Anthem's Member Services receive oral or written complaints, we log it into the tracking system, research the issue and respond to the member. Anthem monitors its Member Services to promote the timely resolution of member complaints. 
How do I appeal a certification or authorization denial?
Check your contract or Certificate to determine the specific process you must follow, or you can call the Member Services number on your ID card during normal business hours, or e-mail us. Once you have contacted us in accordance with the rules set forth in your contract or Certificate, your appeal will be reviewed by Anthem associates who were not involved in the initial denial decision. A clinical peer will be involved in the decision making. Ultimately, if you are not satisfied with the decisions made in the appeals process, your claim may be eligible for review by an independent review organization. Your provider can also appeal denials of these types. You may want to ask your provider to initiate the appeal. Note that in situations where time is of the essence, an expedited appeal process is available when you are waiting to receive treatment pending our decision regarding benefit payment. 
How do I appeal a claim payment or denial?
Check your contract or Certificate to determine the specific process you must follow, or you can call the Member Services number on your ID card during normal business hours, or e-mail us. Once you have contacted us in accordance with the rules set forth in your contract or Certificate, your appeal will be reviewed by Anthem associates who were not involved in the initial denial decision. If necessary, a clinical peer will be involved in the decision making. Ultimately, if you are not satisfied with the decisions made in the appeals process, your claim may be eligible for review by an independent review organization. 
What if waiting for you to decide on my appeal would harm my health?
An expedited review of your appeal is available if we are informed that your medical needs require a faster turn around than our normal appeal process. Your contract or benefit book may describe the time frames for normal or expedited appeals. You can call the Member Services number on your ID card during normal business hours, or e-mail us
If waiting would create harm, we encourage you to continue with your treatment without waiting to hear from us regarding benefit approval/disapproval. Keep in mind that if you are receiving treatment from a network provider, he or she is contractually obligated to use independent medical judgment in treating you. This means that network providers are required to keep your best interests in mind from a clinical perspective, regardless of whether your insurance will cover such treatment. 
My Explanation of Benefits says I received services that I did not have. What should I do?
Call the Member Services number on your ID card, or e-mail your request to us 
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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