Complaints

If you are unhappy for any reason with your coverage or Capital Blue Cross, you can let us know with a complaint.

What is a complaint?

A complaint is a concern or problem you may have with your Capital Blue Cross Medicare PPO or HMO healthcare coverage or with Capital Blue Cross. Federal law guarantees your right to file complaints. The Centers for Medicare and Medicaid Services (CMS) establish the rules for filing a complaint and the rules on what we, as your Medicare Advantage and Prescription Drug Plan, are required to do when a complaint is filed. These rules, in part, state that we must be fair and timely in handling all complaints, and our members cannot be penalized in any way for making a complaint.

There are two types of complaints: a grievance and an appeal. Quality of care and quality of service complaints are classified as grievances. You may also file a marketing compliant, due to an agency or broker who is marketing to you inappropriately, or continuing attempts to make contact after you requested otherwise. These complaints can be filed with Capital Blue Cross Member Services, or by calling the CMS Medicare hotline at 1.800.633.4223. If you are filing a marketing compliant, it is important to include the agent, agency, or broker's name.

What is a grievance?

A grievance is any complaint about the quality of care you are getting from a healthcare provider or pharmacy, or dissatisfaction with the operations, activities, or behavior of our Capital Blue Cross Medicare plans. For example, you would file a grievance if you have a problem with timeliness, appropriateness, or access to a provided health service, procedure, or item. You may also have an issue with a network pharmacist or concerns about access to, or the cleanliness of, a pharmacy.

However, if you have a claims payment issue or a preauthorization determination, you can file an appeal.

How do I notify you about my grievance?

If you have a grievance, we encourage you to call Member Services at 800.779.6962 if you are a Capital Blue Cross HMO member, or 866.987.4213 (TTY 711) if you are a Capital Blue Cross PPO member. We will try to resolve the complaint over the phone. If you request a written response to your grievance during your call, we will respond to you in writing. If we cannot resolve your grievance during the phone call, we have additional processes to review your complaint.

How do I submit my grievance?

You can submit grievances in writing or by fax to Member Services. The grievance must be received by Capital Blue Cross no later than 60 days following the event precipitating the grievance. Either you, or someone you have appointed as your representative, can file a grievance as follows:

In writing:

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

By fax: 888.456.2449

An acknowledgement letter will be issued within five business days of receipt of a written grievance or any grievance concerning quality of care. A resolution letter will be mailed to let you know the outcome of your concern within 30 calendar days of receiving your grievance. We must notify you of our decision regarding your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Capital Blue Cross Medicare PPO and HMO also have an expedited grievance process. You can request an expedited grievance when Capital Blue Cross has denied a request to expedite a preauthorization or an appeal, or if we have taken an extension to review your request.

To learn more about the purposes and operations of the grievance procedures, please call Member Services at 800.779.6962 if you are a Capital Blue Cross HMO member, or 866.987.4213 (TTY 711) if you are a Capital Blue Cross PPO member, Monday through Friday, from 8:00 AM to 8:00 PM with extended hours October 1 through March 31. On weekends and holidays, your call may be forwarded to our secure voice messaging system.