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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.

Appeals

If you are not satisfied with our decision about your care or services you requested, you can file an appeal. An appeal is a formal way of asking us to review and change a coverage 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 1-844-594-5070 if you need help filing an appeal.

The appeal can be made by phone or in writing. If you call us, you must also file your appeal in writing. We can help you complete the appeal form. We will let you know in writing that we received your request for an appeal within five calendar days of receiving it.

If your appeal review needs to be expedited (reviewed more quickly than the standard time frame) because you have an immediate need for health services, you do not need to follow up in writing after you call us. We will let you know in writing that we received your request for an expedited appeal within 24 hours of receiving it.

We will not treat you any differently or act badly toward you because you file an appeal.

To file an appeal, write to:

Appeals
Healthy Blue
P.O. Box 62429
Virginia Beach, VA 23466-2429

To file an appeal by phone, call Member Services at 1-844-594-5070.

Before and during the appeal, you or your representative can see your case file, including medical records and any other documents and records being used to make a decision on your case.

You can ask questions and give any information (including new medical documents from your providers) that you think will help us to approve your request. You may do that in person at 11000 Weston Parkway, Cary, NC 27513, in writing or by phone.

If you need help with understanding the Appeals process, you can contact the Medicaid Managed Care Ombudsman Program.

Standard appeals:

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:

Appeals
Healthy Blue
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 receive our decision about your appeal, you can ask for a Fair Hearing from North Carolina. A Fair Hearing is your opportunity to give more information and facts, and to ask questions about your decision before an administrative 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 our decision about your appeal.

When you request a Fair Hearing, you can also ask for an opportunity to mediate your disagreement. Mediation is an informal voluntary process to see if we can come to an agreement on your case. You do not have to ask for mediation to receive a Fair Hearing. Mediation is guided by a professional mediator who does not take sides. If we do not reach an agreement, you can still have a Fair Hearing. You can also decide not to go through mediation and just ask for a Fair Hearing.

If you need help with understanding the Fair Hearing or Mediation processes, you can contact the Medicaid Managed Care Ombudsman Program.

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 decide your case. 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 Fair Hearing case, we will pay for those services if your case is decided in your favor. Your Fair Hearing might not change the decision we made about your services. When your Fair Hearing case doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.

You can use one of the following ways to request a Fair Hearing:

  1. By fax – 919-431-3100
  2. By mail – Clerk of Court
    Office of Administrative Hearings
    6714 Mail Service Center
    Raleigh, NC 27699-6700

If you are unhappy with your Fair Hearing decision, you can contact the Medicaid Managed Care Ombudsman Program to get more information about your options.

If you have problems with Healthy Blue

We strive to serve you well. If you have a problem, talk with your primary care provider (PCP), call Member Services at 1-844-594-5070 or write to:

Grievance and Appeals Team
Healthy Blue
11000 Weston Parkway
Cary, NC 27513

Most problems can be solved right away. If you have a problem with your health plan, care, provider or services, you can file a complaint with us. This is called a Grievance. Problems that are not solved right away over the phone and any complaint that comes in the mail will be handled according to our complaint procedures described below.

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.

You can also contact the Medicaid Managed Care Ombudsman Program for help with problems you have with your health plan, care, provider or services. They will be able to assist you with your Grievance.

If you are unhappy with Healthy Blue: How to file a complaint

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, Monday through Saturday from 7 a.m. to 6 p.m. Eastern time.

To file in writing, you can write us with your complaint to:

Grievance and Appeals Team
Healthy Blue
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.

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