Pharmacy Appeals and Grievances

You have the right as a Healthy Blue member to ask us to reconsider decisions we have made or to make complaints. These are called appeals and grievances. 

  • An appeal is a request to review an adverse benefit determination.

  • A grievance is a complaint about something other than an adverse benefit determination. 

 

An adverse benefit determination means we: 

  • Deny or limit the approval of a service you ask for. This includes the type or level of service. 

  • Reduce, delay or end a service that was approved before. 

  • Deny a payment for service in whole or in part. 

  • Fail to provide services and resolve grievances and appeals in a timely manner. 

  • Deny a request to get services outside your network if you live in a rural area with only one managed care organization (MCO). 

  • Deny a request to dispute a financial liability, including cost sharing, copays, premiums, deductibles and coinsurance.

     

We want you to be satisfied with your experience with Healthy Blue. If you are not happy with us, you may:

  • File a grievance with us.

  • File an appeal with us for a benefit that:

    • Has been denied.

    • Has a partial OK (this includes the type or level of the service).

    • Has been reduced.

    • Has been stopped.

    • Has been approved then stopped.

    • Has not been given in a timely manner.

    • Has not been reviewed timely by Healthy Blue.

  • Ask for a state fair hearing after using our appeal process.

Appeals

You may ask for an appeal when we make an adverse benefit determination. 

If we make an adverse benefit determination, we will send you and your doctor a letter telling you why. This letter will also tell you how to file an appeal. 

You can ask for an appeal of coverage for a medical service that:

  • Was denied.
  • Was changed. 
  • Was approved and then stopped. 
  • Was not given in a timely manner. 

 

How to File an Appeal 

You must ask for an appeal within 60 calendar days. You may ask for an appeal by:

Healthy Blue 
Appeals Department
P.O. Box 775370
St. Louis, MO 63177
Fax: 844-430-6802

You can have someone file the appeal for you. You must fill out the Appeals Representative Form.  

This same information can also be used to request expedited (rush) appeals.

We will send you a letter letting you know our decision within 30 calendar days from the date we receive your appeal.

Expedited (Rush) Appeals

If you think waiting 30 calendar days may harm your health, we may be able to give you an answer within 72 hours. This is called an expedited (rush) appeal. To ask for a rush appeal, you must tell us why you think waiting 30 calendar days would harm your health. 

We will review the requests for expedited appeals within one working day. If we think waiting 30 calendar days will not harm your health, we will send you a letter 
within two calendar days letting you know. We will complete your appeal as quickly as we can within 30 calendar days. 

If we approve your request for a rush appeal, we will make a decision on your appeal within 72 hours from the date we receive your request. We contact you phone and by mail on the day the decision is made.

Appeal Extensions

We may take an extra 14 calendar days if:

  • You or your representative asks for an extension to resolve your appeal.

  • Healthy Blue needs additional information or time to make a decision. If we do, we will send you a letter with the reason for the extension.

You have the right to file a grievance if you do not agree with the extension decision.

For All Appeals

You (or the person you choose to act on your behalf, including your attorney or a provider) may ask us for a copy of the information we used to make our decision. This includes: 

  • Information about your benefits..

  • Information we used to make the decision.

  • Any other documentation we looked at during the appeals process.

You may ask to see these papers before or during the appeal process. You can request copies of all information related to your appeals for free. 

You have the right to show evidence that supports your request for appeal for us to review. This includes:

  • Written comments.

  • Papers

  • Any other information related to your appeal.

You can show your evidence in person and in writing. If you need more time to send in information, you may add up to 14 calendar days to the appeal time. 

If your provider wishes to speak with our team about the decision made, they can call our Utilization Management (UM) department at 866-902-1689. 

Continuation of Benefits for Appeals

You may keep your benefits for the appealed service while the appeal is pending if you meet all of these requirements:

  • You asked for the appeal within 10 calendar days.

  • The appeal includes services that were: 

    • Delayed.

    • Reduced.

    • Stopped after it was approved.

  • The services were ordered by an approved provider.

  • The time frame for receiving the service hasn’t ended. You are still covered after we gave you our first OK.

  • You ask to keep your benefits.

If we agree to let you keep your benefits for the appealed service while the appeal is pending. You can keep getting the service until one of these happens:

  • You stop your appeal request.

  • 10 calendar days have passed after we sent you our appeal decision to keep the first denial (unless you asked for a state fair hearing within the 10 calendar day period).

  • A state fair hearing officer upholds our denial.

  • The time frame of an approved service has ended.

If the final decision of your appeal is denied, you may have to pay for the costs of the services you received while the appeal was pending.

State Fair Hearing

If you are not happy with the appeal decision, you or the person acting for you has the right to ask for a state fair hearing with SCDHHS. 

You may ask for a state fair hearing within 120 calendar days from the date of the appeal notification letter. To ask for a state fair hearing, you or the person you choose to act for you can:

Division of Appeals and Hearings 
1801 Main St.
P.O. Box 8206
Columbia, SC 29202

For help or questions, call 803-898-2600 or 800-763-9087.

Keeping your benefits during your appeal or state fair hearing process: 

You may keep your benefits for the appealed service while Healthy Blue reviews your appeal and while you wait for your state fair hearing. All of these things must happen: 

  • You ask for the appeal or hearing within 10 calendar days from the date on your adverse benefit determination notice or the intended effective date of the plan’s proposed adverse benefit determination. 

  • The appeal has to do with coverage for a service that has been delayed, reduced or stopped after it was approved. 

  • An approved provider ordered the service. 

  • The original period covered by the original authorization has not expired. 

  • You asked to extend your benefits.

  • They will be in effect until one of these happen: 

  • You stop your appeal or hearing request. 

Ten days have passed after we sent you a letter with our decision to uphold the final denial, unless you asked for a state fair hearing within that 10-day period. 

  • A state fair hearing officer upholds our denial. 

  • The time frame of an approved service has been met.

If the result of the appeal is the same as the original denial decision, you may have to pay for the costs of the services you were given while the appeal was pending. 

* This links to a third-party website. That organization is responsible for the content and privacy policy on its site

 

Download Appeals Forms

Grievances

A grievance is when you tell us you are not happy about anything other than an adverse benefit determination. For example, you can file a grievance if you: 

  • Are not happy with us. 

  • Feel a provider or the health plan has discriminated against you. 

  • Are not happy with the providers who work with us.

How to File a Grievance

You may file a grievance by:

  • Calling us at 866-781-5094 (TTY: 866-773-9634).

  • Writing a letter and sending it to us.

  • Filling out a Member Grievance Form and sending it to us. You can get the form at HealthyBlueSC.com or by calling the previously mentioned number.

You may file a grievance at any time. Clearly state:

  • Who is involved in the grievance.

  • What happened.

  • When it happened.

  • Where it happened.

  • Why you are not happy with your health care services.

Attach any papers that will help us look into your issue. After you complete the form or letter, mail it to:

Healthy Blue
Grievance Department
P.O. Box 775370
St. Louis, MO 63177   
Fax: 844-430-6802

If someone acting on your behalf sends a grievance for you, you are required to give us your written OK. You can mail us your written permission. 

We will look into your issue and decide within 90 calendar days from the time we get the grievance. We will send you a letter with our decision. Our compliance officer investigates discrimination grievances.

 

Grievance Extension

We may take an extra 14 calendar days if:

  • You or your representative asks for an extension to resolve your grievance.

  • Healthy Blue needs additional information or time to make a decision. If we do, we will send you a letter with the reason for the extension.

You have the right to file a grievance if you do not agree with Healthy Blue’s extension decision.

Need to file a medical appeal or grievance?