Part 10 – Appeal and Grievance Program (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 90 Who Handles the Appeal or Grievance Review All appeals and grievances are reviewed by professionals who are knowledgeable about Blue Cross Blue Shield HMO Blue and the issues involved in the appeal or grievance. The professionals who will review your appeal or grievance will be different from those who participated in Blue Cross Blue Shield HMO Blue’s prior decision regarding the subject of your appeal or grievance, nor will they work for anyone who did. When a review is related to a medical necessity denial, at least one reviewer will be an individual who is an actively practicing health care professional in the same or similar specialty who usually treats the medical condition or performs the procedure or provides treatment that is the subject of your review. Response Time for an Appeal or Grievance Review The review and response for an internal formal appeal or grievance review will be completed within 30 calendar days. Every reasonable effort will be made to speed up the review for requests that involve health care services that are soon to be obtained by the member. Blue Cross Blue Shield HMO Blue may extend the 30-calendar-day time frame to complete a review when both Blue Cross Blue Shield HMO Blue and the member agree that additional time is required to fully investigate and respond to the request. Blue Cross Blue Shield HMO Blue may also extend the 30-calendar-day time frame when the review requires your medical records and Blue Cross Blue Shield HMO Blue needs your authorization to get these records. The 30-day response time will not include the days from when Blue Cross Blue Shield HMO Blue sends you the authorization form to sign until it receives your signed authorization form. If Blue Cross Blue Shield HMO Blue does not receive your authorization within 30 working days after your request for a review is received, Blue Cross Blue Shield HMO Blue may make a final decision about your request without that medical information. In any case, for a review involving services that have not yet been obtained by you, Blue Cross Blue Shield HMO Blue will ask for your permission to extend the 30-day time frame if it cannot complete the review within 30 calendar days of receipt of your request for a review. An appeal or grievance that is not acted upon within the time frames specified by applicable federal or state law will be considered resolved in favor of the member. Important Note: If your appeal or grievance review began after an inquiry, the 30-day response time will begin on the day you tell Blue Cross Blue Shield HMO Blue that you disagree with Blue Cross Blue Shield HMO Blue’s answer and would like an internal formal review. Written Response for an Appeal or Grievance Review Once the review is completed, Blue Cross Blue Shield HMO Blue will let you know in writing of the decision or the outcome of the review. If Blue Cross Blue Shield HMO Blue continues to deny coverage for all or part of a health care service or supply, Blue Cross Blue Shield HMO Blue will send an explanation to you. This notice will include: information related to the details of your appeal or grievance; the reasons that Blue Cross Blue Shield HMO Blue has denied the request and the applicable terms of your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross Blue Shield HMO Blue has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross Blue Shield HMO Blue clinical guidelines that apply and were used and any review criteria; and how to request an external review. Appeal and Grievance Review Records You have the right to look at and get copies of records and criteria that Blue Cross Blue Shield HMO Blue has and that are relevant to your appeal or grievance. These copies will be free of charge. Blue Cross Blue Shield HMO Blue will maintain a record of all formal appeals and grievances, including the response for each review, for up to seven years.