If you do not agree with a decision, you may ask that we review the decision. This is called a “grievance” or appeal in your Evidence of Coverage or member handbook. Please read the grievance/appeal section in your Evidence of Coverage or handbook. You can have someone help you with the review. You can use a lawyer, or you can file the review by yourself. You can send us additional information for review. You must send us your grievance/appeal before 180 days has passed from the date you receive your Explanation of Benefits or notice, unless otherwise stated in your Evidence of Coverage or handbook. BlueCross BlueShield of Tennessee will give you an answer within 15 to 60 days, depending on your health benefit plan rules. If your claim is related to an urgent care need, we will review your claim and provide an answer within 72 hours. If your plan is an Employee Retirement Income Security Act of 1974 (ERISA) plan, you may file a civil action after you finish the grievance/appeal process. Also, you may be able to ask for an independent review of this decision. To begin the grievance process, call Customer Service at the number on the back of your BlueCross BlueShield of Tennessee identification card.
You may ask for more details about your request for benefits and/or a decision. If applicable, you may ask for diagnosis and treatment codes and their descriptions. You may also send us a letter asking for the facts we looked at to make our decision and we will send these facts to you for free. You can call our Customer Service Department at the number on the back of your BlueCross BlueShield of Tennessee identification card to a make a request for the details or facts about your claim(s).
For questions about your rights or for assistance, you can contact the Tennessee Department of Commerce and Insurance (TDCI) at 1-800-342-4029 or www.tn.gov/commerce/insurance CIS.Complaints@state.tn.us. You may also write them at 500 James Robertson Pkwy, Davy Crockett Tower, 4th Floor, Nashville, TN 37243. If your plan is self funded, a consumer assistance program may be able to help you at the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). You may contact EBSA at 1-866-444-EBSA (3272) or via email www.askebsa.dol.gov. If you are not sure which assistance program to contact, you may call Customer Service at the number on the back of your BlueCross BlueShield of Tennessee identification card.