If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
Please view the Medicare Advantage appeals process flow chart if you would like a better understanding of how the appeal process works.
How to contact us when you are making an appeal about your medical care
An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your medical care, see Chapter 9 of the Evidence of Coverage (EOC): What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Appeals for Medical Care
Please contact Customer Service at 1-888-494-2583 or TTY 1-800-377-1363 (the
Blue Cross of Idaho