You may file a request for an expedited internal grievance only when you think that Blue Cross Blue Shield of Michigan has wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service, or if you believe we have failed to respond in a timely manner to a request for benefits or payment. If a physician substantiates, either orally or in writing, that adhering to the timeframe for the standard internal grievance process would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, you may file a request for an expedited internal grievance. The commissioner will notify you of the decision, and the commissioner's decision is your final administrative remedy under Public Act 350. The commissioner's staff will recommend whether the commissioner should uphold or reverse our determination.If your request for external review is related to nonmedical issues and is otherwise found to be appropriate for external review, the commissioner's staff will conduct the external review.The commissioner's decision is the final administrative remedy under the Patient's Right to Independent Review Act of 2000. The commissioner must decide within seven business days whether or not to accept the recommendation and will notify you. The assigned independent review organization will recommend within 14 days whether the commissioner should uphold or reverse our determination.We must provide documents and information considered in making our final determination to the independent review organization within seven business days after we receive notice of your request from the commissioner.
If you disagree with our final determination, or if we fail to provide it to you within 60 days of the date we received your original written grievance, you may request an external review from the Department of Insurance and Financial Services.Our written resolution will be our final determination regarding your grievance. If in person, the conference can be held at our headquarters in Detroit, during regular business hours. You can ask that the conference be conducted in person or over the telephone. That will be your opportunity to provide us with any additional information or testimony you want us to consider in reviewing your claim. Once we receive your request for an appeal, we will contact you to conduct or schedule the conference.The form is optional and can be used by itself or with a formal letter of appeal. You can also use the Member Appeal Form (PDF) if you'd like. You or your authorized representative must send us a written statement explaining why you disagree with our determination on your request for benefits or payment.The standard internal grievance process is as follows: The timeframe may be suspended for any amount of time that you are permitted to take to file your grievance, and for a period of up to 10 days if we have not received information we have requested from a health care provider, such as your doctor or hospital. Under the standard internal grievance process, which includes a managerial-level conference, Blue Cross Blue Shield of Michigan must provide you with our final written determination within 60 calendar days of our receipt of your written grievance, unless you grant us additional time.
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