Fillable Blue Cross and Blue Shield of Minnesota Fully-Insured (Blue Cross and Blue Shield of Minnesota)

Fill Online, Printable, Fillable, Blank Blue Cross and Blue Shield of Minnesota Fully-Insured (Blue Cross and Blue Shield of Minnesota) Form

Use Fill to complete blank online BLUE CROSS AND BLUE SHIELD OF MINNESOTA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Blue Cross and Blue Shield of Minnesota Fully-Insured (Blue Cross and Blue Shield of Minnesota)

On average this form takes 7 minutes to complete

The Blue Cross and Blue Shield of Minnesota Fully-Insured (Blue Cross and Blue Shield of Minnesota) form is 1 page long and contains:

  • 0 signatures
  • 5 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross and Blue Shield of Minnesota forms online.

BROWSE BLUE CROSS AND BLUE SHIELD OF MINNESOTA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Blue Cross and Blue Shield of Minnesota 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 Issue
☐
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 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.
X19234R03 (12/20) Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association
Blue Cross and Blue Shield of Minnesota Fully-Insured
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. A full and fair review of
your complaint will be provided.
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 Cross Blue Shield of
Minnesota 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 third party. The review is completed by an independent review organization. The written request for
review must be submitted to the Minnesota Department of Commerce along with a $25 filing fee. The
Minnesota Department of Commerce 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 contact the Minnesota Department of Commerce at any time: 651-539-1600 or 1-800-657-3602
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
PO Box 982800
Attention: 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)
539-1600, 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.
X19234R03 (12/20) Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Blue Cross and Blue Shield of Minnesota Fully-Insured (Blue Cross and Blue Shield of Minnesota)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document