Appeals are a procedure that deals with the review of coverage decisions for services or drugs that you believe you are entitled to receive, including a delay in providing, arranging for, or approving healthcare services or drugs or, on any amounts you must pay for services or drugs. These appeal procedures include a plan reconsideration or redetermination, a second level review of the plan's decision by a Medicare-contracted independent reviewer, a hearing with an Administrative Law Judge (ALJ) or attorney adjudicator, review by the Medicare Appeals Council (MAC), and judicial review. Instructions on how to appeal are included when you receive a letter denying coverage and in your Evidence of Coverage. Instructions on how to appeal are included when you receive a denial on a coverage determination decision letter.

Grievances are an expression of dissatisfaction with any aspect of operations, activities, or behavior of BCBSAZ or its delegated entity in the provision of healthcare items, services, or prescription drugs— regardless of whether remedial action is requested or can be taken. A grievance does not include, and is distinct from, a dispute of the appeal of an organization determination or coverage determination, or a late enrollment determination (LEP). You can file a grievance by phone or in writing using the contact information below.

You may also file a written grievance or appeal by downloading an appeal and grievance form and mailing or faxing to:

---

Further information and assistance

If you have questions or concerns or want to check the status of coverage determinations, appeals, or would like to file a grievance; have questions about making an AOR; or need help in completing the AOR form; please call Member Services.

Acceptable forms of authorization documentation:

• Power of attorney (POA) documentation
• Document showing an individual authorized by a court or authorized under State or other applicable law. An authorized individual can include, but is not limited to, a court-appointed guardian, an individual with durable power of attorney, a healthcare proxy, a person designated under a healthcare consent statute, or an executor of an estate. Legal authorization documentation is valid until its expiration date noted in the document, unless revoked.
• Completed CMS-1696 AOR form. A completed AOR form is valid for one year from the date it has signatures for you and your appointee, unless revoked.
• Equivalent written notice which includes:
• Your name, address, and telephone number
• Appointed individual’s name, address, and telephone number
• Your Medicare beneficiary identifier (MBI) or plan ID number
• Appointed individual’s professional status or relationship to you
• Written explanation of the purpose and scope of the representation
• Statement that you authorize the appointed individual to act on your behalf
• Statement authorizing disclosure of individually identifying information to the appointed individual
• Statement by the individual being appointed that they accept the appointment
• Signature and signature date by you and the individual being appointed. An equivalent notice is valid for one year from the date it has signatures for both you and your appointee, unless revoked.