Navigate Coverage Decisions For Your Medical Care

Medical Prior Authorizations, Appeals and Grievances

Usted tiene derecho a pedirnos que paguemos por un artículo o servicio que crea que debería tener cobertura. Coverage decisions are about your benefits and the amount we pay for your health care or drugs. As your insurance plan, we want you to know your rights and options. This process works in steps and Blue Cross and Blue Shield of Montana is committed to helping you through each step.

Step 1: Ask For a Prior Authorization

Your first step may be to ask for a Prior Authorization. Some health services need approval, called Prior Authorization, from BCBSMT before you get care. Si un servicio no se aprueba, no tendrá cobertura de BCBSMT.

Most often, your health care providers handle this before treatment. However, it is always a good idea to check. Usted y su profesional médico aún podrán decidir seguir adelante con el servicio, pero es posible que tenga que pagar si no se aprueba. Your doctor or an office staff member may ask for a medical prior authorization by phone, fax, or mail.

Visite nuestro Comuníquese con nosotros para encontrar más información.

How Prior Authorization Impacts Our Members

Blue Cross and Blue Shield of Montana runs a Health Equity study of Medicare Advantage prior authorization (PA) trends each year and publicly posts the results on our website. The study looks at the impact of PA on members with one or more of these Social Risk Factors (SRF):

• Has a low-income subsidy
• Is dually eligible for Medicare and Medicaid (LIS/DE)
• Tiene una discapacidad

Our full study, outlined in the documents below, discusses PA approval rates, denial rates and timeframe for review for customers with listed SRFs when compared to customers without listed SRFs.

BCBSMT is invested in delivering equal care for everyone. We will watch and review our PA data each year using the measures outlined by CMS.

Step 2: File an Appeal

Si se niega la cobertura de un artículo o atención médica y usted cree que debería tener cobertura, puede presentar una apelación. An appeal is a formal request asking us to review and changer a coverage decision we made.

Recibirá una respuesta por escrito a su apelación tan pronto como su caso lo requiera. La respuesta será:

• No later than 30 calendar days after we receive your appeal for medical service authorization; or
• A más tardar 60 días calendario después de que recibamos su solicitud de pago.

Podemos agregar al plazo hasta 14 días calendario si usted solicita una extensión.

You may file a medical appeal by fax or mail. Visite nuestro Comuníquese con nosotros para encontrar más información.

Step 3: File a Grievance

You, or an appointed representative, can file a grievance if you have a complaint about what is covered for medical services, the quality of care you receive, the timeliness of service or any other concern (except for the coverage or payment issues listed above).

You can file a grievance by phone, fax or mail. To file a grievance, please visit our Comuníquese con nosotros  de la página.

Importante: debe presentar una inconformidad ante nosotros a más tardar 60 días después del evento o incidente en cuestión.