Part 1 – Member Services (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 5 If you believe that Blue Cross Blue Shield HMO Blue has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Blue Cross Blue Shield HMO Blue Civil Rights Coordinator: by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; or by phone at 1-800-472-2689 (TTY: 711); or by fax at 1-617-246-3616; or by email at [email protected]. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; or by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F HHH Building, Washington, DC 20201; or by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at www.hhs.gov. Your Rights under Mental Health Parity Laws This health plan provides coverage for medically necessary mental health and substance use treatment according to federal and state mental health parity laws. The financial requirements and treatment limits for your mental health or substance use coverage can be no more restrictive than those for your medical and surgical coverage. This means that the cost share amounts (a copayment, coinsurance, or deductible) for services to treat mental health and substance use will be the same or less than those for comparable medical and surgical services. Also, the review and authorization of services to treat mental health or substance use will be handled in a way that is comparable to the review and authorization of medical and surgical services. If Blue Cross Blue Shield HMO Blue makes a decision to deny or reduce authorization of a service, you will receive a letter that explains the reason for the denial or reduction. Blue Cross Blue Shield HMO Blue will send you or your health care provider a copy of the criteria used to make this decision, at your request. You should be sure to read all parts of your Subscriber Certificate to understand your health plan coverage. If you believe that Blue Cross Blue Shield HMO Blue is not compliant with these mental health parity laws, you can make a complaint to the Massachusetts Division of Insurance (the Division) Consumer Services Section. A complaint can be made by phone or in writing. To send a written complaint, you must use the Division’s “Insurance Complaint Form.” You can request a copy of this form from the Division by phone or by mail. You can also find this form on the Division’s Web site at http://www.mass.gov/ocabr/consumer/insurance/file-a-complaint/filing-a-complaint.html. To make a complaint by phone, call 1-877-563-4467 or 1-617-521-7794. If you do make your complaint by phone, you must follow up your phone call by sending your complaint in writing to the Consumer Services Section. When you make a complaint, you must include: your name and address; the nature of your complaint; and your signature authorizing the release of any information about the complaint to help the Division with its review. In addition to filing a written complaint with the Division, you must file an appeal with Blue Cross Blue Shield HMO Blue to have your denial or reduction in coverage reviewed. This may be necessary to protect your right to continued coverage while you wait for an appeal decision. To file an appeal with Blue Cross Blue Shield HMO Blue, you must follow the formal review procedures outlined in Part 10. How You Can Request an Estimate for Proposed Covered Services As required by state law, you or your authorized representative may request an estimate of the costs you will have to pay when your health care provider proposes an inpatient admission, procedure, or other covered service. You can request this cost estimate in writing using an online form or by phone. To send an online written request, log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org. Just follow the steps to request a cost estimate for health care services you are