FILING A GRIEVANCE OR APPEAL

You can review your benefits through your online account. Go to blueshieldca.com/login to sign in or create your account. Once logged in, click on Benefits. 

You can also call Customer Care at the number on your member ID card.

You can choose to have someone file an appeal or grievance on your behalf. For example, this person could be a relative, friend, lawyer, or doctor. They can file appeals and grievances for you and ask for authorizations for you. If you want Blue Shield to speak or respond to the person filing on your behalf, you need to complete the Appointment of Representative form. Both you and your representative must sign this form. Then return it to us at the address shown on the form. Without the Appointment of Representative form, we will not be able to provide any information to the person filing the case on your behalf.  

For more information, view your Member Handbook (Evidence of Coverage).

The timing depends on your specific case. We want to do a thorough review. We may need to gather medical records, speak with your doctor, contact you, and/or consult with a specialist.

For a grievance: We will send you a letter letting you know that we received your notice of your concern within five calendar days. We will provide you with the name of the person who is working on it. We will normally resolve your case within 30 calendar days.

For a standard appeal: We will give you our answer on a request for a medical item or service within 30 calendar days for pre-service (services you have not received yet), or within 30 calendar days for post-service (for services you have already received) after we receive your appeal.

For an expedited (faster) appeal: As long as your request meets the requirements of an expedited appeal, we will give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health circumstances require us to do so.

For more information, see your Member Handbook (Evidence of Coverage). 

The member may have used a service or requested an item that was not covered by their plan. The member may have had a treatment that was not deemed necessary or was not approved.

We can only do expedited (faster) reviews for appeals when there is an imminent and serious threat to the member’s health. This includes 

• Severe pain
• Loss of major bodily function
• Potential loss of life 

You may call to check on the case. We send you a letter within five days of receiving your appeal to let you know when we will respond to you with our decision. If you have added questions or wish to send more information to support your case, please call the number of the coordinator assigned to your case on the letter. You may also call the Customer Care number on your member ID card.

That depends on your specific situation. In some cases, the law requires us to send certain communications by mail. Whenever we can, we will honor your communication preferences.

Each decision letter contains information on what your rights are and what steps you can take next, depending on your case. 

If you received a letter from us telling you that we did not change our decision, or if you never received a decision letter and it has been more than 30 days, you can:

• Ask for an Independent Medical Review (IMR) from the Department of Managed Health Care (DMHC). The DMHC is responsible for regulating healthcare plans. An outside reviewer – someone who is not part of Blue Shield Promise – will provide an impartial review of your case.
• Ask for a State Hearing from the California Department of Social Services (DSS). A judge will review your case.

To learn more about how to request an Independent Medical Review or request a state hearing from DSS, please read your Member Handbook (Evidence of Coverage).

Independent Medical Review (IMR)

  DMHC Help Center phone: (888) 466-2219  (TTY: (877) 688-9891).

  Download IMR form

California Department of Social Services State Hearing
  DMHC Help Center phone: (800) 952-5253  (TTY: (800) 952-8349).

  State Hearing request procedures

If you need help with an appeal or a grievance involving an emergency, you may call DMHC for assistance at (888) 466-2219 (TTY: (877) 688-9891). Calling DMHC does not prohibit any potential legal rights or remedies that may be available to you.

Note that in non-emergency situations, you must first file your appeal or grievance with Blue Shield Promise prior to contacting DMHC for an Independent Medical Review. For Los Angeles, call (800) 605-2556 (TTY: 711). For San Diego, call (855) 699-5557 (TTY: 711).

We work with many groups that oversee health care. Many of them have rules to be sure that the appeals process is fair. Visit the websites listed on your appeals letter to learn more about them.

The person who filed your request (you or your representative) can call the coordinator assigned to your case and let them know. Or, you or your representative can let Customer Care know, and they will tell your case coordinator. To reach Customer Care, call the number on your member ID card.