Guide for Filing an Appeal

If you aren’t happy with a coverage decision, you may file an appeal to get it reviewed.

What is an appeal?

An appeal is a formal request for Capital Blue Cross to review a coverage decision about healthcare services and/or prescription drugs when you are unsatisfied with an initial coverage decision. This includes a decision to deny payment for services and/or covered prescription drugs you already paid for or received. You can file an appeal if you disagree with a decision to stop services you are receiving or if Capital Blue Cross does not pay for a drug, item, or service you think you should be able to receive.

Who can file an appeal?

You or your appointed representative (someone you name to act on your behalf) can request an appeal. Others may already be authorized under state law to act for you, or you can name a relative, friend, attorney, doctor, or someone else.

If you want someone to act on your behalf, you and that individual must sign and date a statement giving the person legal permission to act as your appointed representative. Capital Blue Cross can send you the Appointment of Representative Form CMS-1696 that you both can sign, or you can download the form from the Centers for Medicare and Medicaid Services (CMS).

Your prescribing provider or treating physician can appeal the denial of a preauthorization request on your behalf without an Appointment of Representative form.

You also can have an attorney ask for an appeal on your behalf. You can contact your own attorney, or obtain the name of an attorney from your local bar association or other referral service. There also are groups that will give you free legal services if you qualify.

How soon must you file your appeal?

You need to file your appeal within 65 calendar days from the date on the notice of Capital Blue Cross’ coverage determination. If needed, you can request more time by contacting Capital Blue Cross.

How do I contact Capital Blue Cross?

If you need help filing an appeal, you can call members services at 800.779.6962 if you are a Capital Blue Cross HMO member, or 866.987.4213 if you are a Capital Blue Cross PPO member, with extended hours October 1 through March 31. On weekends and holidays, your call may be forwarded to our secure voice messaging system (TTY 711).

You also can send the appeal to us in writing at:

Capital Blue Cross Medicare PPO Appeals (or)  
Capital Blue Cross Medicare HMO Appeals 
PO Box 779970
Harrisburg, PA 17177-9970

To file a fast appeal, you, your doctor, or your appointed representative can ask Capital Blue Cross to give a fast appeal (rather than a standard appeal) by calling us at the number above. You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or ability to function. A fast decision applies only to requests for services that you have not received yet. Or, you can send a written request to the address above, or fax to 888.456.2449. Be sure to ask for a “fast,” “expedited,” or “72-hour” review.

If your doctor provides a written or oral supporting statement explaining that you need the fast appeal, Capital Blue Cross will automatically treat the request as eligible for a fast appeal.

How soon must Capital Blue Cross decide on your appeal?

For a standard pre-service appeal, Capital Blue Cross has up to 30 calendar days to render a decision, but will make it sooner if your health condition requires us to do so. If Capital Blue Cross does not give you a decision within 30 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.

For a fast decision about a medical service you have not yet received, Capital Blue Cross has up to 72 hours to render a decision, but will make it sooner depending on your health requirements. If a decision is not made within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case.

For a payment appeal, Capital Blue Cross has up to 60 calendar days to make a decision.

Please remember, any time during the request for an appeal process, you can contact members services at 800.779.6962 if you are a Capital Blue Cross HMO member, or 866.987.4213 if you are a Capital Blue Cross PPO member, with extended hours October 1 through March 31. On weekends and holidays, your call may be forwarded to our secure voice messaging system (TTY 711).

You can find additional information about the appeals process in your Evidence of Coverage.