WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 87 Part 10 Appeal and Grievance Program You have the right to a full and fair review when you disagree with a decision that is made by Blue Cross Blue Shield HMO Blue to deny a request for coverage or payment for services; or you disagree with how your claim was paid; or you are denied coverage in this health plan; or your coverage is canceled or discontinued by Blue Cross Blue Shield HMO Blue for reasons other than nonpayment of premium. You also have the right to a full and fair review when you have a complaint about the care or service you received from Blue Cross Blue Shield HMO Blue or from a provider who participates in your health care network. Part 10 explains the process for handling these types of problems and concerns. When making a determination under this health plan, Blue Cross Blue Shield HMO Blue has full discretionary authority to interpret this Subscriber Certificate and to determine whether a health service or supply is a covered service under this health plan. All determinations by Blue Cross Blue Shield HMO Blue with respect to benefits under this health plan will be conclusive and binding unless it can be shown that the interpretation or determination was arbitrary and capricious. Inquiries and/or Claim Problems or Concerns Most problems or concerns can be handled with just one phone call. For help to resolve a problem or concern, you should first call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. A customer service representative will work with you to help you understand your coverage or to resolve your problem or concern as quickly as possible. Blue Cross Blue Shield HMO Blue will consider all aspects of the particular case when resolving a problem or concern. This includes looking at: all of the provisions of this health plan; the policies and procedures that support this health plan; the health care provider’s input; and your understanding of coverage by this health plan. Blue Cross Blue Shield HMO Blue may use an individual consideration approach when Blue Cross Blue Shield HMO Blue judges it to be appropriate. Blue Cross Blue Shield HMO Blue will follow its standard guidelines when it resolves your problem or concern. If after speaking with a Blue Cross Blue Shield HMO Blue customer service representative, you still disagree with a decision that is given to you, you may request a formal review through the Blue Cross Blue Shield HMO Blue Member Appeal and Grievance Program. You may also request a formal review if Blue Cross Blue Shield HMO Blue has not responded to you within three working days of receiving your inquiry. If this does happen, Blue Cross Blue Shield HMO Blue will notify you and let you know the steps you may follow to request a formal review. Appeal and Grievance Review Process Internal Formal Review How to Request an Internal Formal Appeal or Grievance Review To request an internal formal appeal or grievance review, you (or your authorized or legal representative) have three options:  To write or send a fax. The preferred option is for you to send your request for an appeal or a grievance review in writing to: Member Appeal and Grievance Program, Blue Cross Blue Shield