Appeals and grievances
As a Healthy Blue member, you have the right to ask us to reconsider decisions we have made and to make complaints. These are called appeals and grievances.
If you are not happy with our decision about your care, you can file an appeal. An appeal is a formal way of asking us to review and change a decision we made.
You have 60 calendar days after you get a written notice from us to file an appeal.
You can do this yourself or ask someone you trust to file the appeal for you. You can call Member Services at 844-594-5070 (TTY 711) if you need help filing one.
The appeal can be made by phone or in writing. We can help you with the form. We will let you know in writing that we received your ask for an appeal within five calendar days of getting it.
If you think waiting 30 calendar days may harm your health, we may be able to give you an answer within 72 hours from the date we receive your appeal request. This is called an expedited (rush) appeal. To ask for an expedited appeal, you must tell us why you think waiting 30 calendar days would harm your health. If your appeal needs to be reviewed more quickly than the standard time frame because you have an urgent need for help, you do not need to follow up in writing after you call us. We will not treat you badly because you file an appeal.
To file in writing, you can send your appeal to us by:
P.O. Box 62429
Virginia Beach, VA 23466-2429
To file by phone, call Member Services at 844-594-5070 (TTY 711).
Before and during the appeal, you or your rep can see your case file, which includes medical records and any other documents, papers, and records being used to make a verdict on your case.
You may also meet with us in person to give us updates, reports and any other facts that you think are important. Please call 844-594-5070 (TTY 711) to arrange an in-person appeal meeting.
If you have questions about Appeals, you can contact the Medicaid Managed Care Ombudsman Program at 877-201-3750 from 8 a.m. to 5 p.m., every Monday through Friday, except for State holidays.
If we have all the information we need, we will tell you our decision in writing within 30 calendar days.
Expedited (fast track) appeals:
If we have all the information we need, we will call you and send you a written notice of our decision within 72 hours of receiving your request.
If we need more information to make either a standard or an expedited decision about your appeal, we will:
- Write you and tell you what information is needed. For expedited appeals, we will call you right away and send a written notice later.
- Explain why the delay is in your best interest
- Make a decision no later than 14 calendar days from the day we asked for more information
If you need more time to gather your documents and information, just ask. You, your provider or someone you trust may ask us to delay your case until you are ready. We want to make the decision that supports your best health. This can be done by calling Member Services at 1-844-594-5070 or writing to:
P.O. Box 62429
Virginia Beach, VA 23466-2429
Your care while you wait for a decision
When our decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we are making a decision on your appeal. You can also ask a trusted representative to make that request for you.
You must ask us to continue your services within 10 calendar days from the date of the notice that says your care will change or by the time the action takes effect. You or your approved representative may ask to continue services when you first request an appeal by calling or writing to us at the Member Services phone number or address above.
If you ask us to continue services you already receive during your appeal, we will pay for those services if your appeal is decided in your favor. Your appeal might not change the decision we made about your services. When your appeal doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.
If you are unhappy with the result of your appeal, you can ask for a Fair Hearing.
If you don’t agree with a decision we made that reduced, stopped or restricted your services after you get our verdict about your appeal, you can ask for a Fair Hearing from North Carolina. A Fair Hearing is your chance to give more info and facts, and to ask questions about your verdict before a law judge. The judge in your Fair Hearing is not a part of your health plan in any way.
You can ask for a Fair Hearing within 120 calendar days from the day you hear from us about the verdict.
When you ask for a Fair Hearing, you can also ask for someone to mediate your dispute. Mediation is an informal voluntary process to see if we can agree on your case. You do not have to ask for mediation to get a Fair Hearing. Mediation is led by a mediator who does not take sides. If we do not reach a deal, you can still have a Fair Hearing. You can also decide to just ask for a Fair Hearing.
If you need help with Fair Hearing or Mediation, you can contact the Medicaid Managed Care Ombudsman Program at 877-201-3750 from 8 a.m. to 5 p.m., every Monday through Friday, except for State holidays.
Your care while you wait for a verdict
When our finding reduces or stops a service you are getting, you can ask to keep getting the services your provider had ordered while we decide your case. You can also ask a trusted rep to ask for you.
You must ask us to keep getting your services within 10 calendar days from the date of the notice that says your care will change or by the time the action begins. You or your approved rep may ask to keep getting services when you first ask for an appeal by calling or writing to us at the Member Services phone number or address above.
If you ask to keep getting the services you get during your Fair Hearing case, we will pay for those services if your case is decided in your favor. Your Fair Hearing might not change the choice we made about your benefits. When your Fair Hearing case doesn’t change our choice, we may ask you to pay for the care you received while waiting for a verdict.
You can use one of these ways to request a Fair Hearing:
- By fax – 984-236-1871
- By phone - 984-236-1850
- By mail – Clerk of Court
Office of Administrative Hearings
1711 New Hope Church Road
Raleigh, NC 27609
If you are unhappy with your Fair Hearing choice, you can call the Medicaid Managed Care Ombudsman Program at 877-201-3750 from 8 a.m. to 5 p.m., every Monday through Friday, except for State holidays to get more info about your choices.
If you are unhappy with your health plan, provider, care or your health services, you can file a Complaint (also called a Grievance). You can file a complaint by phone or in writing at any time.
To file by phone, call Member Services at 1-844-594-5070.
To file in writing, you can send your complaint to us by:
Grievance and Appeals Team
11000 Weston Parkway
Cary, NC 27513
What happens next:
We will let you know in writing that we got your complaint within five calendar days of receiving it.
We will review your complaint and tell you how we resolved it in writing within 30 calendar days from receiving your complaint.
If your complaint is about the denial of an expedited appeal, we will let you know in writing that we got it within 24 hours of receiving it. We will review your complaint about the denial of an expedited appeal and tell you how we resolved it in writing within five calendar days of receiving your complaint.
You can ask someone you trust (such as a legal representative, a family member or friend) to file the complaint for you. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out the forms, we can help you. We will not make things hard for you or take any action against you for filing a complaint.
If you are not happy with how we resolved your issue, you can file a complaint with the Medicaid Managed Care Ombudsman Program. The Ombudsman Program can look into your concerns and help you with your issue.
Medicaid Managed Care Ombudsman Program
The Ombudsman Program is an independently-operated, non-profit organization whose number one priority is to ensure that individuals and families that receive North Carolina Medicaid and NC Health Choice get access to the care that they need.
The Ombudsman Program can:
- Answer your questions about your benefits
- Help you to understand your rights and responsibilities
- Provide information about Medicaid and Medicaid Managed Care
- Answer your questions about enrolling or disenrolling with a health plan
- Help you understand a notice you have received
- Refer you to other agencies that may also be able to assist you with your health care needs
- Help to resolve issues you are having with your health care provider or health plan
- Be an advocate for members dealing with an issue or a complaint affecting access to health care
- Provide information to assist you with your appeal, grievance, mediation or fair hearing
- Connect you to legal help if you need it to help resolve a problem with your health care