Home > Health Plan > Appeals and Grievances

Appeals and Grievances

If you disagree with a decision about a claim or a request for coverage, you have the right to an appeal. Also, if you have a complaint regarding the plan, the care, or the courtesy received from a contracting provider, or his or her staff, you have the right to a review.

You begin by calling Customer Service at 1–800–217–7878. Blue Choice New England Plan 2 or Fallon Select Care at (508) 799-2100 and they will do their best to resolve the matter as quickly as possible. Please keep a record of the representatives who assist you.

Appeals and grievances procedures
If Customer Service is unable to resolve your problem or concern to your satisfaction, you may write a letter to our Appeals and Grievances Program. All letters must include the following:

• Member’s name
• Identification number
• Description of the issue
• All relevant dates
• Names of Physicians, other medical providers, or administrative staff involved with the case
• Details of any attempts to resolve the case
• Names of Customer Service representatives who assist you

Address the letter to:

Grievance Program
Blue Cross Blue Shield
Landmark Center
401 Park Drive, 01/08
Boston, MA 02215-3326

E-mail: grievances@bcbsma.com
Fax: (617) 246-3616

Or

Fallon Health & Life Assurance Company
10 Chestnut Street
Worcester, MA 01608

Blue Cross Blue Shield and Fallon must receive all appeals and grievances:

• Within one year of the date of treatment;
• Within 30 days of when you were told of the service or claim denial.

Blue Cross Blue Shield / Fallon will investigate the case and contact you in writing of the decision. Blue Cross Blue Shield / Fallon will complete the review and respond “within 30 days of receipt of all necessary information.” Blue Cross Blue Shield / Fallon will make every effort to review appeals quickly for health care services you’re receiving now or plan to receive.

Claims Review Board

If you do not agree with the decision, denying your claim in whole or in part, you or your authorized representative may request a review of that decision by the Teamsters Local170 Health and Welfare Fund Board of Trustees (herein referred to as the “claims fiduciary”). The claims fiduciary is responsible for conducting a full and fair review of your denied claim and for making the final decision regarding benefits payable under this plan. If this decision results in a determination that plan benefits are payable, even though all or a portion of your claim is not covered by the group insurance policy, then such additional benefits would be payable by the plan sponsor.

The procedure for requesting a review by the claims fiduciary of a claim denied in whole or in part it as follows:

• Your request for the review must be directed to the claims fiduciary, must be in writing and must be made within 60 days following receipt by you of the written notice of denial from Blue Cross Blue Shield.
• You may submit additional information, issues and comments in writing with your request for review; and
• You may review pertinent documents (although special approval may be required in certain instances to secure the release of confidential information such as medical records.