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Blue Cross Blue Shield of Minnesota and Blue (Blue Cross and Blue Shield of Minnesota)

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X19236R04 (12/20) Blue Cross
®
and Blue Shield
®
of Minnesota and Blue Plus
®
are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Minnesota and Blue Plus Fully-Insured
COMPLAINT FORM
Inquirer Name: Daytime Phone #:
A
ddress:
City: St: Zip: Patient Name:
Identification Number: Group Number:
Claim Number(s) in question: Date of Service:
Is this your first written request of this issue? ☐ Yes ☐ No
What is your complaint / concern regarding (choose or describe):
☐
Enrollment/Membership Request
☐
Pre-Service Issue (Prior Authorization Denial)
☐
Post-Service Issue (i.e claim, benefit,)
☐
Quality of Care / Quality of Service Complaint
☐
Other – Please specify below
Please provide a narrative description of the complaint or problem and your ideal resolution in
the space provided or attach a separate sheet (include names and dates whenever possible):
I hereby authorize Blue Cross or Blue Plus to forward a copy of this information to the provider if
necessary, to conduct our internal review of the situation.
Signature Date
For specific details on the complaint process, please refer to your Benefit Booklet.

X19236R04 (12/20) Blue Cross
®
and Blue Shield
®
of Minnesota and Blue Plus
®
are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
Blue Cross and Blue Shield of Minnesota and Blue Plus
COMPLAINT FORM
You may appeal a denial or partial denial of your claim by following our complaint procedures. You have the right
to have someone assist you or act on your behalf. If you wish to designate someone to act on your behalf, please
contact customer service to obtain an Authorization for Disclosure of Health Information. If you need help
completing this complaint form, please contact customer service. Your customer service telephone number is
located on the back of your identification card.
1. You may submit any documents, records, or other information that relates to your claim for benefits. You may
file a formal written complaint or contact us by telephone to file a formal complaint.
Pre-Service and Post-Service Medical Determinations: Notice of the resolution will be provided in
writing and mailed to you within 15 days after the formal complaint is received. If a decision cannot be
made within 15 days due to circumstances outside of our control, we may take an additional 4 days to
make a decision, provided we notify you in advance of the extension and the reason(s) for the delay.
Post-Service Non-Medical Determinations: Notice of the resolution will be provided in writing and mailed
to you within 30 days after the formal complaint is received. If a decision cannot be made within 30 days
due to circumstances outside of our control, we may take an additional 14 days to make a decision,
provided we notify you in advance of the extension and the reason(s) for the delay.
2. If you are not satisfied with our decision, you may elect to further appeal to Blue Plus by sending a letter
requesting that our Corporate Appeals Committee review a reconsideration or requesting the Committee to
hear your concerns, either in person or via telephone conference call. A written notification of the Committee's
decision about your appeal will be sent within 30 days from the date your request is received. If you request to
present your concerns before the Committee, a meeting will take place within 40 days of our receipt of your
request and a decision will be made within 5 days following the meeting.
3. If you are still not satisfied with the outcome we have offered and you have completed our internal review
process, including Corporate Appeal (item 2), you may be eligible to submit your complaint for external review
by a third party. The review is completed by an independent review organization. The written request for
review must be submitted to the Minnesota Department of Health along with a $25 filing fee. The Minnesota
Department of Health may waive this fee in cases of financial hardship. Additional information regarding this
process will be provided in our notification to you.
4. You may submit a complaint to the Commissioner for the Minnesota Department of Health for investigation at
any time by calling (651) 201-5100 or toll-free at 1-800-657-3916.
5. If your group health plan is subject to ERISA, once you have completed the formal complaint process, you
have the right to file suit in Federal Court under Section 502(a) of ERISA.
Please send this completed form to the address below or fax the form to (651) 662-2745
Blue Cross and Blue Shield of Minnesota and Blue Plus
PO Box 982800
Attn: Appeals and Grievances
El Paso, TX 79998
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-
8000, 1-800-382-2000 (toll free), or call the customer service number on the back of your identification card.
For TTY:
Call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at
1-800-627-3529 (TTY, Voice, ASCII, Hearing Carry Over), or 1-877-627-3848 (Speech-to-Speech).
Attention: If you want free help translating this information, call the above number.
Atención: Si desea ayuda gratis para traducir esta información, llame al número que aparece arriba.
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Completed 20 June 2022

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