File a Grievance or Appeal

For BlueJourney HMO and BlueJourney PPO Members

Please complete the Appoint a Representative form to have another person represent you during the appeal process.

Required fields are noted with an asterisk *.

Member Information

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Provider Information
Claim Information
* Reason For Grievance or Appeal

Your Complaint Rights

Refer to your evidence of coverage for more information.

If you have questions or would like an Appoint a Representative form mailed to you, please contact us Monday through Friday, 8:00 am — 8:00 pm.

BlueJourney HMO Members: 800.779.6962 (TTY: 711) 
BlueJourney PPO Members: 866.987.4213 (TTY: 711)

Appeals Involving Medical Advantage Plan Coverage

Fast Track Appeal: (48 hour review) 
The fast track appeal applies to coverage termination of skilled nursing, home health and CORF services. You may appeal by requesting an expedited review of the case by the Quality Insights of Pennsylvania (QIO) in the state where you receive the services.

Appeal: (30 day pre-service, 60 day post-service review) 
An appeal is a documented request for any dispute concerning payment, failure to arrange or continue to arrange for, what a member believes are covered services.

Expedited Appeal: (72 hour review) 
Available only for pre-service: It is a documented or verbal request for any dispute concerning payment, failure to arrange or continue to arrange for, what a member believes are covered services. For expedited appeals either the member or the member's doctor believes applying the standard time frame could seriously jeopardize the member's life, health or ability to regain maximum function.

Grievances Involving Medicare Advantage Plan Coverage

Standard Grievance: (30 day review) 
This is a documented or verbal dispute no later than 60 calendar days after the event.

Expedited Grievance: (24 hour review) 
This is a documented or verbal dispute concerning the plan's refusal to expedite an organization determination or reconsideration (appeal) or invoking an extension to an organization determination or reconsideration time frame.

Issues Involving Prescription Drug Coverage

Appeal: (7-day review) 
This is a documented request for a dispute concerning a failure to arrange or continue to arrange for, what a member believes are covered services.

Appeal: (14-day review) 
This is a documented request for a dispute concerning a payment determination.

Expedited Appeal (72-hour review) 
Available only for pre-service: A document or verbal request for a dispute concerning payment, failure to arrange or continue to arrange for, what a member believes are covered services.

Standard Grievance: (30-day review) 
This is a documented or verbal dispute regarding issues such as: quality of care or services received, pharmacy waiting times, pharmacy delay or other similar concerns.

Expedited Grievance: (24-hour review) 
This is a documented or verbal dispute concerning the plan's refusal to expedite a coverage determination or redetermination (appeal) and the member has not received the drug in question.

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Updated November 1, 2019

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