HealthMate Coast-to-Coast

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Ideal if you’re looking for: A traditional health plan that helps you control premiums

HealthMate Coast-to-Coast offers coverage for many services with no copayments or coinsurance in network once the deductible is met. Coinsurance applies to out-of-network services only.

Plan Features

  • Coverage for most services once the deductible has been met, which provides security and makes it easier for employees to plan for expenses
  • No wellness requirements for employees

HealthMate Coast-to-Coast Checklist

We integrate our pharmacy management with our medical management for a big picture approach. We’re able to manage both prescription and medical claims costs while also providing more coordinated care for your employees, saving you time and money.

Our preferred drug list emphasizes cost-effective generic and brand name drugs. It also helps your employees understand that alternative medications provide the same medical care at a lesser cost, and that expensive, brand name drugs aren’t necessarily better.

This brochure highlights enhancements to our products and services, which will help guide you in your healthcare choices.

The Value of Blue (PDF 1.57MB)
 

Complaints and Appeals

The Grievances and Appeals Unit (GAU) is here to provide a thorough, timely, and unbiased review of complaints, and administrative and medical appeals. The purpose of this process is to assure that benefits are administered equitably according to member contracts, regulatory mandates, accrediting standards, and Blue Cross policies. This process will ensure that objective, equitable outcomes are achieved.

Complaints and Administrative Appeals

A complaint is a verbal (spoken) or written communication explaining that you are unhappy with any part of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is fixed right away by clearing up the misunderstanding or supplying the appropriate information to your satisfaction.

An administrative appeal is a verbal or written request for us to reconsider (make another decision about) a full or partial denial of payment for services that were denied (not covered) because we decided that the services were excluded (not included) from coverage or because you or your provider did not follow Blue Cross’s requirements.

We will let we know we received your complaint or administrative appeal in writing or by phone within 10 business days. The GAU will conduct a complete review of your complaint or administrative appeal and respond in the time frames below.

Level 1 Complaint

We will respond to your Level 1 complaint in writing within 30 business days of the date we receive your complaint. The letter with our decision will provide you with the reason for our response and information on the next steps available to you, if any, if you are not satisfied with the outcome (result) of the complaint.

Level 2 Complaint (when applicable)

A Level 2 complaint may be submitted only when you have been offered a second level of complaint in the letter that included your Level 1 decision. The GAU will conduct a complete review of your Level 2 complaint and respond to you in writing within 30 business days. The letter with our decision will provide you with the reason for our response and information on the next steps if you are not satisfied with the outcome of the complaint.

Administrative Appeal

If you wish to file an administrative appeal, you must do so within 180 days of receiving a denial of benefits.  We’ll respond to your administrative appeal in writing within 60 calendar days of receiving it. The letter with our decision will provide information about why that decision was made.

Blue Cross does not offer a Level 2 administrative appeal. You may notify the State of Rhode Island Department of Health regarding your concerns. Please refer to the Judicial Review section below for additional information.

Medical Appeals

A medical appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that we decided were:

  • Not medically necessary, or
  • Available in our participating provider network.

If we deny payment for a service for medical reasons, you’ll receive the denial in writing. The written denial you receive from us will explain the reason for the denial and provide specific instructions for the medical appeals process.

Level 1 Review

You may request a Level 1 review of any matter that is subject to medical appeal by making a request (preferably in writing) for such a review to Blue Cross within 180 calendar days of the initial decision letter.

You will receive written notification of the decision on a Level 1 pre-service review within 15 calendar days of receipt of the medical appeal request. If you are requesting reconsideration (Level 1 review) of a service that was denied after you already obtained the service (retrospectively), you will receive written notification of our decision within 15 business days of our receipt of the appeal.

Level 2 Review – Applicable only to members with employer group coverage
You may request a Level 2 appeal review (preferably in writing) if our denial was upheld during the Level 1 review process. Your Level 2 appeal review will be reviewed by a provider in the same specialty as your treating provider. You must submit your request for a Level 2 appeal review within 180 calendar days of the date of the reconsideration decision letter. Upon request for a Level 2 review, Blue Cross will provide you with the opportunity to inspect the medical file and add information to the file.

You will receive written notification of the decision on a Level 2 pre-service review within 15 calendar days of the appeal request. If the service you are requesting review of was denied after you already obtained the service (retrospectively), you will receive written notification of our decision within 15 business days of our receipt of receipt of the appeal request.

Note: You may request an expedited (faster) review of denied services if the circumstances are urgent or if you are in an inpatient setting. You or your doctor must call the GAU at (401) 459-5784 or 1-800-528-4141 or fax your request to (401) 459-5005. An expedited decision will be made within two business days following receipt of the request, or sooner if the urgent nature of the circumstances require and it is reasonably possible to make such a decision in a shorter period of time. Members in urgent situations and while receiving an ongoing course of treatment may proceed with expedited external review at the same time as the internal appeals process.

External Appeal – Available to members with employer group coverage after the second level appeal denial. Available to members with individual coverage after the first level appeal denial.

If you remain dissatisfied with the decision of Blue Cross’s internal review (Level 1 and Level 2) processes, you may request an external review by an outside review agency. An external appeal is a complete reexamination of your case by an independent review organization (IRO). For members covered by group health plans, this external appeal is a voluntary level of appeal. This means that you may choose to participate in this level of appeal, or you may file suit in an appropriate court of law (see Judicial Review).

To request an external review, you must submit your request in writing to Blue Cross within four months of your receipt of the medical appeal denial notification. Members are not required to bear any costs when requesting a case be sent for external review to an IRO. Blue Cross will forward your letter and the entire case file to the IRO within five business days, or two business days for an expedited appeal. Upon receipt of the necessary information, the IRO will notify you of the result of your appeal within 10 business days, or two business days for an expedited appeal. If the IRO overturns our decision, we will authorize or pay for the services in question.

Judicial Review

If you are dissatisfied with the final decision of the IRO, you are entitled to a final review (a Judicial Review). This review will take place in an appropriate court of law.

For members covered by group health plans, you have the right to bring a civil action following an adverse benefit determination on review pursuant to section 502(a) of the Employee Retirement Income Security Act of 1974. For these members, you may bring such action either after your appeal is decided for administrative appeals, or prior to the external review level for medical appeals.

Note: At anytime, you may request copies of your case file (free of charge) by contacting us at the telephone number(s) listed above or in your decision letter.

How to File any Complaint or Appeal

If you’re unhappy with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of services or benefits, please call Customer Service at the number on the back of your member ID card. A Customer Service Representative will log your inquiry and try to resolve your concern. If your concern is not resolved to your satisfaction, you may file a complaint or appeal verbally with the customer service representative.

You may also file a complaint or appeal in writing. To do so, you must provide all of the information below:

  • Your name, address, and member ID number
  • A summary of the complaint or appeal, any previous contact with Blue Cross, and a brief description of the relief or solution you are seeking
  • Any additional information such as referral forms, claims, or any other documentation that you would like us to review
  • The date of the incident or service
  • Your signature, if sending in writing

 

If someone is filing a complaint or any appeal for you, you must designate (name) someone other than your healthcare provider to represent you in your appeal. Blue Cross requires a signed, written request from you authorizing that person to act on your behalf.

Please mail the complaint or appeal to:

 

Blue Cross & Blue Shield of Rhode Island

Attention: Grievances and Appeals Unit

500 Exchange Street

Providence, Rhode Island 02903

*The description provided above is only a summary of benefits provided by the plan. Other exceptions, reductions and limitations may also apply to your benefits. For complete benefit details please see the subscriber agreement for the plan.