Your Rights and Responsibilities

If you’re unhappy about a decision we made or care you received, you have the right to file a complaint. If you have a problem with our services or providers, we would like you to tell us about it. Please call Member Services and we’ll try to solve your problem on the phone.

If we can’t take care of the problem when you call us, you can file a grievance. You may file a grievance in writing or on the phone.

• To file by phone, call Member Services at 844-396-2329 (TTY 711)
• To file in writing, send us a letter and include:
  • The date of the problem or incident.
  • The names of people involved.
  • Details about the problem.

You can ask Member Services for help writing the letter.

Send your letter to:

Quality Management Department
Anthem Blue Cross and Blue Shield Healthcare Solutions
Desert Canyon, Building 9
9133 W. Russell Road
Las Vegas, NV 89148

When we get your call or letter, we will:

• Send you a letter within five calendar days letting you know we received your grievance.
• Look into your grievance in a timely manner.
• Send you a letter telling you what we’ve done to address the issue within 90 calendar days of getting your grievance.

Second level grievance review

If you’re not happy with our decision and your grievance is about anything below, you may file a second level grievance review:

• Your ability to receive benefit coverage
• Access to care
• Access to services
• Payment for services

Ask us for a second level grievance review in writing within 90 calendar days of the date on the original grievance resolution letter we sent you. Mail your second level grievance review request
to the address above. We’ll send you a letter within five calendar days to let you know we got your request. Someone at a higher level than the reviewer who looked at your initial grievance
request will look at your second level request. We’ll send you a letter with our decision within 30 calendar days.

The second level grievance review is the final level of review for grievances.

Some Anthem services and benefits need prior authorization (preapproval). This means your PCP must ask us to approve the services and/or benefits before you get them.

The Utilization Review team looks at requests and decides if the service is medically needed and if it’s a covered benefit. We’ll share our decision with your PCP by fax or phone within 14 calendar days after receiving the request and clinical information.

Your PCP can ask for an expedited review if a delay could cause grave harm to your health. We’ll notify your doctor of our decision within three days of getting the request.

If we say we won’t pay for the service or we approve less than the amount or type requested, you or your doctor can ask for an appeal of our decision.

Important: Emergency services, post-stabilization services and urgent care don’t need prior approval.

If we tell you we won’t pay for recommended care and services, you can file an appeal. There may be times when Anthem says we will deny, end, or reduce a service we approved. We may also say we won’t pay for all or part of the care your provider asked for. If this happens, we’ll send you a letter called a Notice of Adverse Benefit Determination.

If you disagree with our decision, you, your provider, or a representative can appeal our decision. We must have your written permission to allow your provider or representative to appeal on your behalf.

What is an appeal? An appeal is when you can ask Anthem to look again at the care your doctor asked for and we said we would not pay. You must ask for an appeal within 60 calendar days from the date on the letter that said we would not pay for the service.

How do I file an appeal? You can request an appeal by calling us, writing us a letter, or sending us a completed Request for Appeal Review form.

If you have more information to give us like medical records or provider letters, you can send it in with your request or letter or you can bring it to us in person. You can also ask us for more information to help you understand why we would not pay for the service requested.

You can ask for an expedited appeal if you or your doctor thinks you need the services for an emergency or life-threatening illness. You can ask for an expedited appeal by calling Member Services at 844-396-2329 (TTY 711) instead of submitting your request in writing. If your appeal is to be processed as an expedited request, we will call you and let you know our decision within
72 hours. If we do not agree to expedite your appeal, we will review your request as a routine appeal.

Can someone help me file an appeal? You can have someone else help you with the appeal process. This person can be your provider, legal representative, relative, friend, or spokesperson. If someone helps you, you must give him or her your written permission.

During the appeal process, you or your representative has the right to present evidence, documentation, information, and allegations of fact or law either in person or in writing.

You both can look at your records or information regarding this decision before and during the appeal process. Also, you may request a copy (at no cost) of the documents and guidelines used to make the decision.

What happens after I file my appeal? A doctor who has not seen your case before or worked for the doctor who made the original decision will look at your appeal and make a decision.

When will I receive a decision? When we get your request, we will send you a letter within five calendar days to let you know we got your appeal.

If you asked for an expedited appeal, we will let you know our decision within 72 hours of getting your appeal request. If this is a routine appeal, we will let you know our decision within 30 calendar days of getting your appeal.

What if I don’t agree with your appeal decision? If you do not agree with our final decision, you can ask for a fair hearing from the state. You must ask for this hearing within 120 calendar days from the date on the final decision letter from Anthem. Fair hearing information will be sent to you with the Anthem letter telling you our final decision if your appeal is not decided fully in your favor.
What if I am receiving services now that may be affected by your decision? If we reduce, suspend, or terminate coverage of a service you are now receiving and you want to keep getting the service during your appeal, you must fill out and submit the Request to Continue Benefits form. The form must be submitted within 10 calendar days from the date on the notice stating we will not pay for the service or by the date the notice says your service will end or be reduced, whichever is later.

You must be prepared to be held financially responsible for these services if our final appeal decision or the decision of the state fair hearing officer is not in your favor.

Who do I call if I have questions about filing an appeal? If you have questions or need help, please call Member Services at 844-396-2329 Monday through Friday from 7 a.m. to 7 p.m. Pacific time. If you have a special need, we will give you extra help to file your appeal. If you are deaf or hard of hearing, call 711.
 

• State Fair Hearing Form - English
• State Fair Hearing Form - Spanish
• Appeal Review Form - English
• Appeal Review Form - Spanish