![]() Response Time: Within 90 days of submitting your tier 2 formal appeal, you will receive a tier II formal appeal determination on whether your appeal is approved or denied and your administrative and appeal rights under the SHBP are considered exhausted with no right to further appeals. You must continue to comply with all SHBP Eligibility and Enrollment Provisions.Therefore, you will no longer be eligible for coverage with the SHBP. Special note for retirees: When your SHBP coverage is terminated, it CANNOT be reinstated unless you return to work in a benefits eligible position that offers SHBP coverage. During the public health emergency (PHE), Blue Cross and Blue Shield of Minnesota (Blue Cross) extended the timely filing edit in our claims system to 180 days for commercial and Medicare plan claims to reduce claim denials and appeals. You must continue to make premium payments as billed or your coverage will be cancelled.You will receive an automated acknowledgement email.Complete form below to submit a Tier 2 Formal Appeal.Blue Cross Medicare Advantage Member Services. Must be submitted within thirty (30) days of the Tier 1 Telephone Review Determination. You may also file an expedited appeal by phone.Request for Tier 2 Formal Appeal: final step of the appeals process.You should receive a determination immediately, unless verification is required. Call SHBP Member Services 1-80 to request Tier 1 Telephone Review.Request for Tier 1 Telephone Review must occur within 30 days of adverse action (e.g., if retiree disputes October 1 rate increase due to failure to provide Medicare Part B information, Tier 1 Telephone Review must be filed no later than October 31).Request for Tier 1 Telephone Review (mandatory): first step of the appeals process.This means SHBP automatically denies your appeal. Timely appeal: Failure to file your appeal (tier 1 telephone review and/or tier 2 formal appeal, as applicable) within the time allowed, bars any further appeal and your administrative and appeals rights are considered exhausted. Additional supporting information and/or documentation will not be accepted or reviewed after your Tier II Formal Appeal is submitted. Submit All Necessary Information and Documentation: For tier 2 formal appeals, you must submit all relevant information and documentation supporting your request for a tier 2 formal appeal at the time your appeal is submitted. If you have not completed a tier 1 telephone review, your request for a tier 2 formal appeal will be automatically denied, and if the timeframe has passed for you to request a tier 1 telephone review, your administrative and appeal rights under SHBP are considered exhausted with no right to further appeals. ![]() You must have completed and received a determination on your tier 1 telephone review prior to requesting a tier 2 formal appeal. The Eligibility & Enrollment Appeals process begins with the Tier I Telephone Review handled by SHBP Member Services representatives and for Members who are dissatisfied with the Tier I Telephone Review determination, they may submit a Tier II Formal Appeal handled internally by SHBP Member Services subject matter experts. BlueCard ® members from other BCBS Plans, which have their own appeal procedures and time frames (some Plans have a 180-day window for submitting an appeal). Medicare Advantage Enrollment and Medicare Part B.Qualifying Events and Special Enrollment Events.If you still have any questions about appeals and grievances after reviewing these materials, please call BCBSAZ customer service for help at the number on the back of your member ID card.The following areas are examples of Eligibility and Enrollment appeals: The guideline also includes optional forms you and your provider may use to file an appeal or grievance. Use these resources and the guidelines to understand the steps you must take to dispute a decision. The customer service section of your benefit plan booklet also has contact information for the appeals and grievances offices for both BCBSAZ and any delegated vendors serving your plan. All of these documents have information telling you where to file your initial appeal or grievance request. Also check your Explanation of Benefits (EOB) document, monthly health statement and any precertification denial letter. Look at the Standard Appeal Packet sent to you at enrollment (see below to view or download). Information on where and how to file an appeal or grievance is available in several places. You can also appeal and grieve delegated vendor decisions. BCBSAZ may use delegated vendors to administer some benefits for some plans. If you disagree with BCBSAZ's decision about a precertification request, or with how a claim was processed, you have the right to appeal or grieve those decisions.
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