Appeals and Grievances

Appeals

An appeal is a way for you to ask for a review of BCBSIL's actions. You might want to file an appeal if we:

• Don't approve care your provider asks for
• Stop offering a service that was approved before
• Don't pay for care your primary care provider (PCP) or other doctor asked for
• Don't give you care or answer an appeal in a timely manner
• Don't approve a service for you because it wasn't in our network

If we decide a requested service can't be approved or should be reduced, stopped or ended, we'll send you a Notice of Action letter that tells you:

• What action was taken and why
• Your right to file an appeal, how and when to do it
• Your right to ask for a State Fair Hearing and how to do it
• Your right in some cases to ask for an expedited appeal and how to do it
• Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services

Grievances:

A grievance is a complaint about anything not about a denied, reduced or ended service. If you have a complaint about a provider or the care they offered, let us know right away. We have special procedures in place to help members who file a grievance and will do our best to help. Filing a complaint won't change your health care services or your plan coverage. 

You might want to file a grievance if:

• You had trouble getting an appointment with your provider in a reasonable amount of time
• You were unhappy with the care or treatment you received
• A doctor or BCBSIL employee didn't respect your rights
• A doctor or BCBSIL employee was rude to you
• A doctor or BCBSIL employee didn't respect your cultural or other special needs