For BlueCardВ® (out-of-area) members, be sure to check the memberвЂ™s benefit book for appeal information.Дocumentation to include when supporting a BCBSAZ member appeal/grievance Note: Not all states allow providers to initiate an appeal/grievance on behalf of a member.

In these cases, a provider who is appealing on a memberвЂ™s behalf should use the Authorized Representative Designation Form to send us the patientвЂ™s authorization allowing the provider to receive appeal information on the patientвЂ™s behalf.ДЄ provider initiating an appeal on behalf of a member should send the patient a copy of all information shared with us in connection with the appeal or grievance. However, a few BCBSAZ plans for self-funded groupsВ require specific member authorization before the provider can pursue an appeal for the member.

A parent acting on the behalf of a minor.

The treating provider acting on the memberвЂ™s behalf.

For most BCBSAZ plans, the following individuals are always authorized to appeal or grieve a decision and do not need any special authorization form: Laws and benefit plans vary regarding a providerвЂ™s right to initiate an appeal/grievance on behalf of a member.

Rescinds the memberвЂ™s coverage under the plan.

Determines that the member is not eligible for coverage under the benefit plan.

Finds that a service is not covered because it is experimental or investigational.

Finds that a service is not medically necessary.

Finds the member responsible for payment of cost share (copay, deductible, coinsurance, access fee, balance bill) for a plan benefit.

Finds the member ineligible for a benefit under his or her plan.

Fails to provide or pay for a benefit covered under the memberвЂ™s plan.

Denies, reduces, or terminates the memberвЂ™s plan benefits.

Denies a claim for services already received.Denies a request for preauthorization of a service not yet received.Below is a summary of those issues that can be appealed or grieved through our member appeal and grievance process.

Bcbs timely filing limit 2021