Medical coverage decisions
You have the right to ask Blue Cross of Idaho Care Plus to pay for items or services you think should be covered. This is called an "organization determination" (also called a coverage decision).
An organization determination (referred to here as a coverage decision) is a decision Blue Cross of Idaho Care Plus makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need.
You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us. For expedited coverage decisions, phone or fax.
Call:
1-888-494-2583 (TTY 711)
Fax:
208-331-8829
Mail:
Blue Cross of Idaho Care Plus
P.O. Box 8406
Boise, ID 83707
8 a.m. - 8 p.m.
Oct. 1 - Mar. 31, seven days a week
Apr. 1 - Sept. 30, Monday - Friday
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "expedited" (fast) deadlines. A "fast coverage decision" is called an "expedited determination."
| Request | Standard response | Expedited response |
|---|---|---|
| Prior Authorization (pre-service) | ||
| Prior Authorization (pre-service) | Within 14 days | Within 72 hours |
| Claim (post service) | ||
| Claim (post service) | Within 60 days | N/A |
| Grievances and other complaints | ||
| Grievances and other complaints | Within 30 days | N/A |
To get a fast coverage decision, you must meet two requirements:
If your doctor tells Blue Cross of Idaho Care Plus that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision
If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.
In some cases we might decide a service is not covered or is no longer covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation as to why we said no and instructions on how to appeal our decision.
For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.
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.
For more information please visit the medicare.gov website's detailed description of the Medicare Advantage appeals process.
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).
Call or Fax
Please contact Customer Service at 1-888-494-2583 or TTY 711 (the TTY number requires special telephone equipment and is only for people who have difficulties with hearing or speaking). We are available from 8 a.m. to 8 p.m. (MST) on these days:
Fax
1-208-331-8829
Write
Blue Cross of Idaho
P.O. Box 8406
Boise, ID 83707
You or your authorized representative (someone you name to act for you), may file an appeal. Your representative can be a relative, friend, advocate, attorney, doctor, or someone already appointed by the State to act on your behalf. Call Customer Service if you need help naming a representative.
You must send us a statement naming the person you want to act for you by using the Appointment of Representative (Nombramiento de Representante) form. You and your authorized representative must sign and date the statement and then deliver, mail or fax your statement or form to Blue Cross of Idaho.
Deliver in-person
Appeals and Grievance Coordinator
Blue Cross of Idaho
3000 E. Pine Avenue
Meridian, ID 83642
Mail
Appeals and Grievance Coordinator
Blue Cross of Idaho
P.O. Box 8406
Boise, ID 83707-2406
Fax
208-331-8829
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