As a Blue Cross member, you are a partner in your health—both with your doctor and with Blue Cross. That’s why it’s important to understand your rights and responsibilities. If you have any questions about the member rights and responsibilities listed below, please call the Lifespan Employee CARE Center at (401) 429-2102 or 1-866-987-3706, Monday through Friday 8:00 a.m. – 8:00 p.m., Saturday 8:00 a.m. – noon. We will be happy to explain anything you have questions or concerns about.

If you ever feel that any of your rights as a member have not been recognized, please let us know.

As a Blue Cross member, you have the right to:

• Receive information about Blue Cross, our services, our practitioners and providers, and your member rights and responsibilities.
• Be treated with respect and with recognition of your dignity and right to privacy.
• Receive a second opinion at the applicable copay, coinsurance, and/or deductible.
• Participate with practitioners in making decisions about your healthcare. This includes receiving information concerning your diagnosis, treatment, and prognosis in terms that can be reasonably understood. In the event your doctor considers access to such information inadvisable by reason of medical condition, age, and/or lack of decision-making capacity, the information will be given to an appropriate person on your behalf.
• Have a candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
• Know about resources such as customer service representatives, complaints and appeals processes, and language interpretation resources that can help you answer questions and resolve problems and complaints.
• Voice complaints or file appeals about Blue Cross or the medical care you receive.
• Make recommendations regarding Blue Cross’s rights and responsibilities policies for members.
• Receive impartial (fair) access to treatment. This means that you have the right to all medically indicated treatment that is a covered benefit, regardless of your race, religion, sex, sexual orientation, gender identity, national origin, cultural background, disability, or financial status.
• Receive medical care and services provided by health professionals who meet the professional standards established by Blue Cross.

As a Blue Cross member, you have the responsibility to:

• Fulfill financial obligations. You are responsible for paying applicable premiums, deductibles, copays, coinsurance, and other fees as outlined in your plan documents.
• Know the extent and limitations of your healthcare benefits, as described in your member benefit booklet.
• Understand your health problems and participate in developing mutually agreed upon treatment goals. This includes certain circumstances in which your doctor may recommend a course of treatment that is not covered by your plan. Ask your doctor to clearly explain your treatment plan and what is expected of you until you fully understand.
• Schedule regular preventive care appointments with your primary care provider (PCP). This includes routine physical exams, health screenings, and immunizations.
• Give accurate and complete information (to the extent possible) about your present and past medical condition that Blue Cross and your healthcare provider need in order to provide care. You should report unexpected changes in your condition to your healthcare provider.
• Follow the treatment plan and instructions for care that you have agreed to with your healthcare provider. If you feel that you cannot follow through with your treatment, tell your healthcare provider.
• Present your member ID card whenever you seek care and use the card only as appropriate. Make sure that other people do not use your member ID card.
• Keep appointments. Know your provider’s appointment cancellation policy, and promptly cancel any appointment that you do not need or cannot keep.
• Be considerate of healthcare professionals, staff, and other patients.
• Seek care through your PCP whenever possible (except in emergencies).

If you need interpreter services
We have Spanish-speaking customer service representatives, and we have access to interpreter services in numerous languages. This includes languages originating from Africa, Asia, Europe, the Middle East, South America, the Caribbean, and the Pacific Islands. We can also assist your provider in obtaining in-office sign language services. For more information on these services, call the Lifespan Employee CARE Center at (401) 429-2102 or 1-866-987-3706, Monday through Friday 8:00 a.m. – 8:00 p.m., Saturday 8:00 a.m. – noon.

At Blue Cross, we work with your doctor to ensure that you get the care you need at the right time and in the appropriate setting. For some types of care, it is recommended or required that you get prior approval (preauthorization) from Blue Cross.

Your PCP or specialist may contact us or one of our vendors for preauthorization for some kinds of care. This care includes, but is not limited to, the following:

• Pre-scheduled, elective hospital admissions (such as surgery)
• Certain radiology services (including MRI, MRA, CAT scans, and nuclear cardiac imaging)
• Certain prescription drugs

In some cases, we may review your care and decide that it could have taken place in a more appropriate setting or determine that it is not a covered benefit under your plan. If we deny coverage for a service, you may appeal our decision. (See below for details.)

If you choose to receive care from a provider outside of the plan’s network, you are responsible for paying all charges up front and submitting a claim to Blue Cross for consideration of payment. For healthcare services covered under your plan, we reimburse you or the non-network provider, less any copays and deductibles, based on a percentage of Medicare fee schedules or allowed amounts. When a Medicare fee or allowed amount is not available for the service you received, we reimburse you or the non-network provider, up to the lesser of our allowance; the non-network provider’s charge; or the benefit limit.

How to submit for reimbursement
Ask the non-network provider who treated you for an itemized statement (including diagnosis and procedures) and a receipt. The receipt should include the following information: diagnosis code/description, health service code/CPT code/description of service or item, charge for each service, patient ID number, patient name, provider name, provider address, the provider’s letterhead/logo, provider tax ID number, and specific date(s) of service. Submit clear black-and-white copies of these items to Blue Cross with a letter explaining your request. Be sure your letter includes your name, address, and member ID number.

Send your letter to:
Blue Cross & Blue Shield of Rhode Island
Attn: Claims Department
500 Exchange Street
Providence, RI 02903

Remember, if you receive medical services that are not covered by your plan, you are responsible for those costs. If you have any questions, call the Lifespan Employee CARE Center at (401) 429-2102 or 1-866-987-3706, Monday through Friday 8:00 a.m. – 8:00 p.m., Saturday 8:00 a.m. – noon.

The Grievances and Appeals Unit (GAU) provides 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 operations 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 an oral or written request for BCBSRI to reconsider a full or partial administrative denial or a request for BCBSRI to reconsider an adverse decision that affects the member’s ability to receive benefit coverage, access to care, access to services, or any unresolved member complaints.

We will let you 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 timeframes below.

Level 1 complaint
We will respond to your complaint in writing within 30 calendar 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.

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 30 calendar days if you appeal before you’ve received the services, or 60 calendar days if you appeal after you’ve received the services. 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 contact the Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline (RIREACH) with 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 appropriate; or
• Experimental or investigational.

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.

Reconsideration 
You may request reconsideration 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 pre-service request for reconsideration within 15 calendar days of receipt of the request. If you are requesting reconsideration 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 request.

Appeal of Request for Reconsideration 
You may request an appeal (preferably in writing) if our denial was upheld during the reconsideration process. Your appeal will be reviewed by a provider in the same specialty as your treating provider. You must submit your request for an appeal within 45 calendar days of the date of the reconsideration decision letter. Upon request for an appeal, 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 pre-service appeal 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 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. An expedited decision will be made within 72 hours following receipt of the request, or sooner if the urgent nature of the circumstances requires a more immediate response. 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 after the appeal denial)
If you remain dissatisfied with the decision of Blue Cross’s internal review processes, you may request an external review by an outside review agency. An external appeal is a complete re-examination of your case by an independent review organization (IRO). 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. Please refer to the judicial review section below for additional information.

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 calendar days, or 72 hours 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 any time, you may request copies of your case file (free of charge) by contacting us at (401) 459-5784 or 1-800-528-4141 or at the number listed in your decision letter.

How to file any complaint or appeal
If you’re unhappy with any aspect of our operations, 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 the Lifespan Employee CARE Center at (401) 429-2102 or 1-866-987-3706, Monday through Friday 8:00 a.m. – 8:00 p.m., Saturday 8:00 a.m. – noon. We 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 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