1. You or your covered dependent (member) has one hundred eighty (180) days from receipt of an Adverse Benefit Determination to file an appeal. An appeal must meet the following requirements.
a. Be in WRITING; and,
b. Be sent (via US mail) to: BlueCross Blue Shield of South Carolina (BCBS), Claims Service Center, Post Office Box 100300, Columbia, SC 29202
c. Must state that a formal appeal is being requested and include all pertinent information regarding the claim in question; and,
d. Must include your name, the covered dependent’s name (if applicable), date of services received, address, identification number and any other information, documentation or materials that support the appeal.
2. A member may submit written comments, documents, or other information in support of the appeal, and will (upon request) have access to all documents relevant to the claim. A person other than the person who made the initial decision will conduct the appeal. No deference will be afforded to the initial determination.
3. If the appealed claim involves an exercise of medical judgment, McLeod will consult with an appropriately qualified health care practitioner with training and experience in the relevant field of medicine. If a health care professional was consulted for the initial determination, a different health care professional will be consulted on the appeal.
4. The final decision on the appeal will be made within the time periods specified below:
- Pre-service claim – BCBS will decide the appeal within a reasonable period of time, taking into account the medical circumstances, but no later than thirty (30) days after receipt of the appeal.
- Urgent care claim – A member may request an expedited appeal of an Urgent Care Claim. This expedited appeal request may be made orally to the HR Service Center at 843-777-2595, and an HR Service Center representative will communicate with you by telephone or facsimile. The Plan Administrator or their designee will decide the appeal
within a reasonable period of time, taking into account the medical circumstances, but no later than seventy-two (72) hours after receipt of the request for an expedited appeal.
- Post-service claim – BCBS will decide the appeal within a reasonable period of time, but no later than sixty (60) days after receipt of the appeal.
- Concurrent care claim – The Plan Administrator or designee will decide the appeal of Concurrent Care Claims within the time frame set forth above depending on whether such claim is also a Pre-Service Claim, an Urgent Care Claim or a Post-Service Claim.
5. Notice of final internal appeals determination:
- State specific reason(s) for the Adverse Benefit Determination;
- Reference specific provision(s) of the Plan of Benefits on which the benefit determination is based; State that a member is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the claim for Benefits.
- Disclose and provide any internal rule, guideline, or protocol relied on in making the Adverse Benefit Determination;
- If the reason for the Adverse Benefit Determination on appeal is based on a lack of Medical Necessity, Investigational or Experimental Services or other limitation or exclusion, explain the scientific or clinical judgment for the determination (or state that such information will be provided free of charge upon request);
- Include a statement regarding your right to request an external review; and
- Include a statement regarding your right to bring an action under section 502(a) of ERISA.
6. McLeod retains BCBS assistance in making the determination on appeal. Regardless of its assistance, BCBS is only acting in an advisory capacity and is not acting in a fiduciary capacity. McLeod at all times retains the right to make the final determination.
External Review Procedures
After a member has completed the appeal process, they may be entitled to an additional external review of their claim at no cost. An external review may be used to reconsider a member’s claim if BCBS has denied, either in whole or in part. In order to qualify for external review, the claim must have been denied, reduced, or terminated. After a member has completed the appeal process, (and an Adverse Benefit Determination has been made) a member will be notified in writing of the right to request an external review. A member should file a request for external review within four (4) months of receiving the notice of BCBS’s decision. In order to receive an external review, a member will be required to authorize the release of medical records (if needed in the review for the purpose of reaching a decision on the claim).
Within six (6) business days of the date of receipt of a member’s request for an external review, BCBS will respond by either:
- Assigning the request for an external review to an independent review organization and forwarding the member’s records to such organization; or,
- Notifying the member in writing that the request does not meet the requirements for an external review and the reasons for BCBS’s decision.
The external review organization will take action on a member’s request for an external review within forty-five (45) days after it receives the request for external review from BCBS.
Expedited external reviews are available if a member’s Physician certifies that they have a serious medical condition. A serious medical condition, used in this provision, means one that requires immediate medical attention to avoid serious impairment to body functions, serious harm to an organ or body part, or that would place a member’s health in serious jeopardy. A member may be held financially responsible for the treatment, a member may request an expedited review of BCBS’s decision if BCBS’s denial of Benefits involves Emergency Medical Care and the member has not been discharged from the treating hospital.