Appeals and Grievances
At Blue Cross and Blue Shield of Illinois, we take pride in making sure you get the care you need. But if you have a complaint about how we handle any services provided to you, you can file an appeal or grievance.
What is a Grievance?
A grievance is a complaint about any matter besides a service that has been denied, reduced or ended. BCBSIL takes member complaints seriously. We want to know what is wrong so we can serve you better. If you have a complaint about a provider or about the quality of care you received, let us know right away. BCBSIL has special procedures in place to help members who file a grievance. We will do our best to answer your questions and help with your concern. Filing a complaint will not change your health care services or your plan coverage.
You may want to file a grievance if:
- You had trouble getting an appointment with your provider in a reasonable amount of time
- You were unhappy with the care or treatment you received
You might also want to file a grievance if your provider or a BCBSIL employee:
- Did not respect your rights
- Was rude to you
- Did not respect your cultural needs or other special needs you may have
What is an Appeal?
An appeal is a way for you to ask for someone to review our actions. You might want to file an appeal if BCBSIL:
- Does not approve a service your provider asks for
- Stops a service that was approved before
- Does not pay for a service your PCP or other provider asked for
- Does not give you the service in a timely manner
- Does not answer your appeal in a timely manner
- Does not approve a service for you because it was not in our network
If BCBSIL decides that a requested service cannot be approved, or if a service is reduced, stopped or ended, you will get a Notice of Action letter from us. You must file your appeal within 60 calendar days from the date on the Notice of Action letter. This letter will tell you:
- What action was taken and the reason for it
- Your right to file an appeal and how to do it
- Your right to ask for a State Fair Hearing and how to do it
- Your right in some cases to ask for an expedited appeal and how to do it
- Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services
How to File an Appeal or Grievance
There are different ways to file an appeal or grievance (complaint). Check the options below. After you file an appeal, we will call to tell you our decision and send you and your authorized representative a Decision Notice. Refer to your Member Handbook to learn more about Appeals and Grievances.
Call Us
- Call Member Services at 1-877-860-2837.
- If you do not speak English, we can provide an interpreter at no cost to you.
- If you are hearing impaired, call the Illinois Relay at 711.
Write to Us
Blue Cross Community Health Plans
Attn: Grievance and Appeals Unit
P.O. Box 660717
Dallas, TX 75266-0717
Fax Us
Send a fax to: 1-866-643-7069
Appeal a Pharmacy Service
If you would like to appeal a pharmacy service, you can:
Call Us
- Call Member Services at 1-877-860-2837.
- If you do not speak English, we can provide an interpreter at no cost to you.
- If you are hearing impaired, call the Illinois Relay at 711.
Write to Us
Blue Cross Community Health Plans
Attn: Grievance and Appeals Unit
P.O. Box 660717
Dallas, TX 75266-0717
Fax Us
Send a fax to 1-855-212-8110.
What Happens After You File an Appeal?
After you receive the BCCHP appeal Decision Notice in writing, you do not have to take any action. Your appeal file will be closed. However, if you do not agree with the decision made on your appeal, you can act by asking:
- For a State Fair Hearing Appeal within 120 calendar days of the date on the Decision Notice.
- For an External Review of your appeal within 30 calendar days of the date on the Decision Notice.
Both of these are reviews done by someone outside of BCCHP. You can choose to ask for both a State Fair Hearing Appeal and an External Review. Or you may choose to ask for only one of them.
How to Request a State Fair Hearing Appeal or External Review
There are different ways to request a State Fair Hearing Appeal or External Review. Check your Member Handbook to learn more about the processes for both.
Request an External Review
Submit a letter to request an external review of an appeal decision.
- Write to Us:
Blue Cross Community Health Plans
Attn: Grievance and Appeals Dept.
P.O. Box 660717
Dallas, TX 75266 - Fax Us:
Standard Fax: 1-866-643-7069
Expedited Fax: 1-800-338-2227
Request a State Fair Hearing Appeal
To make a request, you can:
- Ask your local Family Community Resource Center to give you an appeal form to request a State Fair Hearing. They will help you fill it out if you wish.
- Visit . You can set up an ABE Appeals Account and submit a State Fair Health Appeal. This will allow you to track and manage your appeal online. You will be able to check important dates and notices related to the State Fair Hearing. You will also get information about how to submit documentation.
Need to file a State Fair Hearing Appeal related to your medical services or items, or Elderly Waiver (Community Care Program (CCP)) services? You can:
- Write to:
Illinois Department of Healthcare and Family Services
Bureau of Administrative Hearings
69 W. Washington Street, 4th Floor
Chicago, IL 60602
- Fax to: 1-312-793-2005
- Email: HFS.FairHearings@illinois.gov
- Or Call: 1-855-418-4421 (TTY: 1-800-526-5812)
Need to file a State Fair Hearing Appeal related to mental health services or items, substance abuse services, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services, or any Home Services Program (HSP) service? You can:
- Write to:
Illinois Department Human Services Bureau of Hearings
69 W. Washington Street, 4th Floor
Chicago, IL 60602
- Fax to: 1-312-793-8573
- Email: DHS.HSPAppeals@illinois.gov
- Or Call: 1-800-435-0774 (TTY: 1-877-734-7429)
