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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.

We want you to be satisfied with your experience with Healthy Blue. If you’re 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.
    • Hasn’t been given in a timely manner.
    • Hasn’t been reviewed timely by Healthy Blue.
  • Ask for a State Fair Hearing after using our appeal process.

Appeals

An appeal is when you’re unhappy about an adverse or negative decision we made about your benefits and you want us to look at our decision again. You may ask for an appeal if you received a Notice of Adverse Benefit Determination letter from us saying coverage for a medical service:

  • 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.
  • Hasn’t been given in a timely manner.
  • Hasn’t been reviewed timely by Healthy Blue.

You must ask for an appeal within 60 calendar days from the date on the Notice of Adverse Benefit Determination letter sent by mail. You may ask for an appeal by:

  • Calling us at 866-781-5094 (TTY 866-773-9634). If you file an appeal by calling, you must confirm the request in writing or with the Member Appeal Request Form we’ll send you.
  • Writing a letter and sending it to us at:
    Healthy Blue
    Appeals Department
    P.O. Box 62429
    Virginia Beach, VA 23466-2429
    Fax: 866-216-3482

If someone acting on your behalf sends an appeal for you, you’re required to sign an Appeal Representative Form. To get this form, go to the bottom of this page. Or, call the Customer Care Center at 866-781-5094 (TTY 866-773-9634).

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

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, and the extension is in your best interest. If we do, we’ll send you a letter with the reason for the extension.

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

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 you call and ask for an expedited appeal, you don’t need to send a signed, written appeal.

An appeals nurse reviews requests for expedited appeals within one working day. If the appeals nurse thinks waiting 30 calendar days won’t harm your health, we’ll send you a letter within two calendar days explaining we’ll complete your appeal as quickly as we can within 30 calendar days.

If the appeals nurse approves your request for an expedited appeal, we’ll make a decision on your appeal within 72 hours from the date we receive your expedited appeal request. We’ll notify you of our decision by phone and by letter the day the decision is made.

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 coverage and benefits.
  • Medical guidelines used to make the decision.
  • Any other documentation we looked at during the appeal process.

You may ask to see these papers before or during the appeal process. We provide members access to and copies of all documentation relevant to their appeal for free upon request.

You have the right to show evidence that supports your request for appeal for us to review. This includes written comments, papers, or 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.

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 from the date we mailed the Notice of Adverse Benefit Determination letter.
  • The appeal has to do with coverage for a service that has been:
    • 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’re 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.
  • Ten calendar days have passed after we sent you the Notice of Adverse Benefit Determination letter with our appeal decision to uphold 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’re not happy with our appeal decision, you or the person you choose to act on your behalf have the right to ask for a state fair hearing with the Division of Appeals and Hearings at the South Carolina Department of Health and Human Services (SCDHHS). You must submit your request in writing within 120 calendar days from the date on the Notice of Resolution letter we mailed you. The Notice of Resolution letter explains our decision to deny your appeal.

To ask for a state fair hearing, you must submit your request in writing to:

Division of Appeals and Hearings
1801 Main Street
P.O. Box 8206
Columbia, SC 29202
803-898-2600 or 800-763-9087
Fax: 803-255-8206
appeals@scdhhs.gov

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

  • You asked for the hearing within 10 calendar days from the date we mailed the final Notice of Adverse Benefit Determination letter.
  • The hearing has to do with coverage for a service that has been:
    • Delayed.
    • Reduced.
    • Stopped after it was approved.
  • The service was ordered by an approved provider.
  • The time frame for receiving the service hasn’t ended. You’re 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 hearing is pending, you can keep getting the service until one of these happens:

  • You stop your hearing request.
  • A state fair hearing officer upholds our denial.
  • The time frame of an approved service has ended.

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

Grievances

A grievance is when you’re unhappy with something other than a decision about benefits and you want us to look into it. If you’re not happy with us or the providers we work with, you or the person you choose to act on your behalf may file a grievance with us. Here are a few reasons you might file a grievance:

  • You feel a provider or employee was rude to you.
  • You feel your member rights weren’t respected.
  • You’re unhappy with the quality of your care or services.

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 on this page or by calling the number above.

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 aren’t 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 62429
Virginia Beach, VA 23466-2429

Fax: 866-216-3482

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

We’ll research your issue and decide within 90 calendar days from the time we receive the grievance. We’ll send you a letter with our decision. Discrimination grievances are investigated by our compliance officer.

Grievance extensions

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, and the extension is in your best interest. If we do, we’ll send you a letter with the reason for the extension.

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