Children s Health Insurance Program (CHIP) Brought to You by Capital BlueCross Certificate of Coverage Vision CHIP coverage is issued by Keystone Health Plan Central through a contract with the Commonwealth of Pennsylvania. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations. Capital BlueCross and Keystone Health Plan Central are independent licensees of the Blue Cross and Blue Shield Association. As an independent company, the products and services of National Vision Administrators are not Capital BlueCross products and services. National Vision Administrators is solely responsible for these vision care programs. ABC-44 ()
AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) GROUP VISION INSURANCE CERTIFICATE OF COVERAGE ABOUT THIS CERTIFICATE: This Certificate describes vision insurance provided to Eligible Members under the Children s Health Insurance Program. President Secretary CHILDREN S HEALTH INSURANCE PROGRAM (CHIP) Benefit Schedule Participating Provider Non-Participating Provider Vision Examination Benefit Benefit Copay Amount N/A N/A Maximum Benefit $38 $38 Benefit Frequency is once every 6 months from the Date of Service per Plan Year. Standard Eyeglass Lenses Benefit (per pair) Maximum Benefit Single Vision Standard Lenses $36 $36 Bifocal Standard Lenses $48 $48 Trifocal Standard Lenses $58 $58 Aphalkic/Lenticular Standard Lenses $95 $95 Single Vision Polycarbonate Lenses $25 $25 Bifocal/Trifocal Polycarbonate Lenses $30 $30 Lens Options are non-covered items. Benefit Frequency is once every 6 months from the Date of Service per Plan Year. Eyeglass Frame Benefit Maximum Benefit $55 $30 Benefit Frequency is once every 12 months from the Date of Service per Plan Year. Contact Lenses Benefit In lieu of Standard Eyeglass Lenses and Eyeglass Frames Benefit. Maximum Benefit for Contact Lenses: Medically Necessary (per pair) 100% of UCR 100% of UCR Benefit Frequency is when medically necessary. C3/cf/contracts/vision
Definitions Benefits means vision care services, as shown in the benefit schedule, that are covered under this policy. Date of Service means the calendar date on which a specific service was provided or materials were ordered, which are payable under the policy. Eligible Member means a person that satisfies the eligibility requirements and is therefore eligible to receive Benefits under this Policy. Immediate Family Member means a person who is related to the Insured Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-inlaw, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). Insured Person means the Eligible Member who: (1) has been issued a program identification card; (2) has enrolled for coverage under the Policy; and (3) for who premium is paid while covered under the Policy. Ophthalmologist means a person who is licensed by the state in which he or she practices as a Doctor of Medicine or Osteopathy and is qualified to practice within the medical specialty of ophthalmology, who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder. Optically Necessary/Optical Necessity means a prescription or a change of prescription is required to correct visual function. Optician means a person or business licensed by the state in which services are rendered to manufacture, grind and/or dispense lenses and frames prescribed by either an Optometrist or an Ophthalmologist, who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder. Optometrist means a person licensed to practice Optometry as defined by the laws of the state in which his or her services are rendered, who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder. Optometry means the profession of examining eyes and treating certain defects by means of corrective lenses. Participating Ophthalmologist means an Ophthalmologist who is a Participating Provider. Participating Optician means an Optician who is a Participating Provider. Participating Optometrist means an Optometrist who is a Participating Provider. Participating Provider means an Ophthalmologist, Optician or Optometrist who has elected to enter into a contract with the Vision Benefit Manager and who is listed in the Participating Provider Directory. Participating Provider Directory means the directory of Participating Providers. Policyholder means the holder of this insurance policy. C3/cf/contracts/vision 2
Standard Lenses means any size lenses manufactured from glass or plastic, which are optically clear; standard multifocal lenses include segments through flattop 35 for plastic bifocal and lenticular lenses, glass trifocals through flattop 28 and plastic trifocals through flattop 35. Sub-Normal Optical Correction means vision is not correctable to better than 20/70 in the better eye by use of conventional lenses. Vision Benefit Manager means National Vision Administrators, LLC, which administers benefits for CHIP. AIG Life underwrites the vision benefits. Vision Examination means an examination of principal vision functions. A vision examination includes, but is not limited to, case history, examination for pathology or anomalies, job visual analysis, refraction, visual field testing and tonometry, if indicated. The exam will be consistent with the community standards, rules and regulations of the jurisdiction in which the provider practice is located. Eligible Members To be eligible to be enrolled under this Policy, an individual must be a child under age nineteen (19) who meets all necessary qualifications to be eligible for benefits under the CHIP program until no longer eligible. Vision Benefits The amount of Vision Benefits payable under the Policy and the manner of payment is determined by whether the Insured Person utilizes the services of a Participating Provider or a non-participating Provider. The Insured Person will receive a program identification card or cards for use while covered under the Policy. Participating Provider When the Insured Person incurs the services of a Participating Provider, they may be required to present the program identification card to the Participating Provider. The Participating Provider may: (1) verify eligibility; and (2) notify the Insured Person of any out-of-pocket expenses. Non-Participating Provider If the Insured Person incurs services of a non-participating Provider, the Insured Person will be required to pay the full cost of such services at the time of purchase. If the Insured Person incurs charges under the Contact Lenses Benefit for Sub-Normal Optical Correction from a non-participating Provider, they may be required to present the program identification card so that the non-participating Provider may contact the Vision Benefit Manager for pre-approval. Vision Examination Benefit. If the Insured Person incurs charges under the Vision Examination Benefit, the Company will pay such expenses up to the applicable Vision Examination Maximum Benefit at the Benefit Frequency shown in the Benefit Schedule, subject to the Exclusions, provided: 1) such expenses were incurred while the Insured Person was covered under the Policy; and 2) the Insured Person has paid any applicable Copay, as shown in the Benefit Schedule. C3/cf/contracts/vision 3
Standard Eyeglass Lenses Benefit. If the Insured Person incurs expenses for Standard Lenses, the Company will pay such expenses up to the Standard Eyeglass Lenses Maximum Benefit at the Benefit Frequency shown in the Benefit Schedule, subject to the Exclusions, provided: 1) such expenses were incurred while the Insured Person was covered under the Policy; and 2) the Insured Person has paid any applicable Copay, as shown in the Benefit Schedule. Eyeglass Frame Benefit. If the Insured Person incurs expenses for eyeglass frames, the Company will pay such expenses up to the applicable Eyeglass Frame Maximum Benefit at the Benefit Frequency shown in the Benefit Schedule, subject to the Exclusions, provided: 1) such expenses were incurred while the Insured Person was covered under the Policy; and 2) the Insured Person has paid any applicable Copay, as shown in the Benefit Schedule. Contact Lenses Benefit. If the Insured Person incurs expenses for contact lenses, the Company will pay such expenses up to the applicable Contact Lenses Maximum Benefit at the Benefit Frequency shown in the Benefit Schedule, subject to the Exclusions, provided: 1) such expenses were incurred while the Insured Person was covered for the applicable optical correction type under the Policy; and 2) the Insured Person has paid any applicable Copay, as shown in the Benefit Schedule. In addition to the above, benefits will not be payable for expenses incurred for Sub Normal Optical Correction, unless: the Participating or non-participating Provider of such services makes a request, in writing, to the Vision Benefit Manager that a special contact lens or lenses is necessary to achieve the best possible correction for the Insured Person; and 2) the Vision Benefit Manager, upon review of such request, approves the request. Limitations If the Contact Lenses Benefit is payable in lieu of the Standard Eyeglass Lenses Benefit and the Eyeglass Frame Benefit, the Insured Person shall be eligible to receive benefits under the Standard Eyeglass Lenses Benefit or the Eyeglass Frame Benefit only after the Contact Lenses Benefit Frequency has ended. Exclusions Benefits will not be payable under the Policy for expenses incurred for: 1. Professional services and/or materials in connection with: a. Blended bifocals, no line, or progressive addition lenses. b. Compensated or special multi-focal lenses. c. plain (non-prescription) lenses. d. Anti-reflective, scratch, UV400, or any coating of lamination applied to lenses. e. Subnormal visual aids. f. Tints other than solid. g. Orthoptics, vision training and developmental vision procedures. 2. Broken, lost or stolen lenses, contact lenses or frames. 3. Contact lenses that are not medically necessary or not approved by the Vision Benefit Manager. 4. Medical or surgical treatment of the eye, unless such treatment is performed during a Vision Examination, subject to the applicable Vision Examination Maximum Benefit shown in the Benefit Schedule. C3/cf/contracts/vision 4
5. Services or materials which are payable under any Workers Compensation Act or similar law or any public program other than Medicaid. 6. Services or materials rendered by a provider other than an Ophthalmologist, Optometrist, or Optician acting within the scope of his or her license. 7. Vision examination for vision materials that may be required as a condition of employment, including, but not limited to, industrial or safety glasses. 8. Services rendered after the date the Insured Person ceases to be covered under this Policy, except when vision materials ordered before coverage ended are delivered and the services are rendered to the Insured Person within 31 days from the date of such order. Regardless of the Optical Necessity, benefits are not available more frequently than that which is specified in the Benefit Schedule. C3/cf/contracts/vision 5
Filing a Vision Claim HOW TO FILE A CLAIM: If you or any of your eligible dependents incurs expenses for benefits payable under the vision policy from a participating provider, you or they will pay: (1) the difference in cost (at the time of the purchase) between the maximum allowable benefit and the cost for such purchase; and (2) any applicable Copay, as shown in the vision schedule of benefits. No claim form will need to be filed. If you or any of your eligible dependents incurs expenses for benefits payable under the vision policy from a non-participating provider, you or they will be required to pay the full cost at the time of the purchase. A proof of claim must be submitted, consisting of: (1) an itemized receipt from the non-participating Provider; (2) the Date of Service; (3) the name of the non-participating Provider; (4) the charges incurred from such non-participating Provider; and (5) the name of the Insured Person on whose behalf the charges were incurred, to the Vision Benefit Manager at PO Box 2187, Clifton, NJ 07015 in order to be reimbursed for the amount payable under the Policy. The receipt should also include the Policyholder s name and the Policy Number. Timely Filing: Timely filing of claims is important. Claims submitted twelve (12) months or more beyond the date of service will not be eligible for payment. COMPLAINT AND GRIEVANCE PROCEDURES: Whenever a member disagrees with an adverse benefit determination or has an objection regarding a participating provider or Capital BlueCross operations or management policies, the member may seek review by complying with the complaint and grievance procedures set forth in this section. Definitions In addition to the defined terms used elsewhere in this Certificate of Coverage, the defined terms set forth below apply to the complaint and grievance procedures. Complaint: A dispute or objection by a member regarding a participating provider or benefit coverage, operations, or management policies of Capital BlueCross, which has not been resolved by Capital BlueCross and has been filed with Capital BlueCross or with the Department of Health or the Insurance Department of the Commonwealth. The term does not include a grievance. Grievance: A written request by a member, or a provider acting on the member s behalf and with the appropriate written consent of the member, to have Capital BlueCross or a certified external review organization review the denial of reimbursement for a health care service where the denial was based on lack of medical necessity and appropriateness. C3/cf/contracts/vision 6
Expedited Complaint or Grievance: A complaint or grievance pertaining to: a service that Capital BlueCross must approve in advance, where the member s life, health, or ability to regain maximum function would be placed in jeopardy by delay occasioned by following the time frames applicable to Capital BlueCross standard complaint or grievance procedures. a service that, in the opinion of a physician with knowledge of the member s condition, the member would be subject to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. Pre-Service Complaint or Grievance: A complaint or grievance pertaining to a service for which Capital BlueCross requires preauthorization or a referral before the service is rendered and for which service has not yet been rendered. Post-Service Complaint or Grievance: A complaint or grievance pertaining to a service which has been rendered and for which payment or reimbursement of the health care service is being appealed. Classification of Complaints and Grievances If a member disagrees with Capital BlueCross classification of a dispute as a complaint or a grievance, the member has the right to question the classification by contacting either: Bureau of Consumer Services Pennsylvania Insurance Department 1209 Strawberry Square Harrisburg, PA 17120 Toll-free: 1-877-881-6388 OR Bureau of Managed Care Pennsylvania Department of Health Health and Welfare Building, Room 912 7th and Forster Streets Harrisburg, PA 17120 Toll-free: 1-888-466-2787 Authorized Representative At any time during the complaint and grievance process, a member may choose to designate a representative to participate in the process on the member s behalf. To designate an individual to serve as an authorized representative, the member must complete, sign, date, and return a Capital BlueCross Authorized Representative Designation Form. Members may request this form from Customer Service by calling the following telephone numbers: Telephone: Members should use the phone number on their ID card; or call 1-800-543-7101 Telephone (TDD): 1-800-242-4816 Capital BlueCross communicates with authorized representatives only after Capital BlueCross receives a member s completed, signed, and dated designation form. The member s designation form will remain in effect until the member notifies Capital BlueCross in writing that the member s representative is no longer authorized to act on the member s behalf, or until the member designates a different individual to act as the member s authorized representative. C3/cf/contracts/vision 7
How to File a Complaint Filing A Complaint Problems regarding participating providers, coverage issues, or Capital BlueCross operations or policies can often be resolved by calling Capital BlueCross Customer Service Department. If a problem cannot be resolved over the telephone, a member may register a formal complaint. A member must file a complaint with Capital BlueCross within one hundred eighty (180) days of the circumstances giving rise to the complaint. Complaints may be filed by contacting Capital BlueCross Customer Service Department at the following address and telephone numbers: Capital BlueCross First Level Complaint PO Box 779518 Harrisburg, PA 17177-9518 Toll-free: 1-800-543-7101 TDD: 1-800-242-4816 Capital BlueCross will acknowledge receipt of the complaint in writing. Capital BlueCross acknowledgment letter will explain that Capital BlueCross classifies the dispute as a complaint and will provide the appropriate address and telephone number for the member to contest Capital BlueCross classification of the dispute as a complaint. The acknowledgment letter will also describe the complaint process and the member s rights. Members may, but are not required to, appoint a representative to act on their behalf at any time during the complaint process. Please see the instructions at the beginning of this section on how to designate an individual to act on a member s behalf. The member or the member s representative may review information related to the complaint. Capital BlueCross will provide copies of this information to the member or the member s representative without charge upon request. The member or the member s representative may submit additional material to be considered by Capital BlueCross. The member or the member s representative may also request the aid, at no charge, of a Capital BlueCross employee in preparing the complaint. First Level Complaint Review Capital BlueCross will investigate all complaints. A First Level Complaint Review Committee will follow the time frames identified below: Pre-Service Complaints Post-Service Complaints Capital BlueCross First Level Complaint Review Committee will reach a decision and notify the member and the member s representative within thirty (30) days of receipt of the complaint. Capital BlueCross First Level Complaint Review Committee will reach a decision within thirty (30) days of receipt of the complaint and will notify the member and the member s representative within five (5) business days of the decision. C3/cf/contracts/vision 8
The notice will include the basis for the decision and the procedures to file an appeal of the decision. The decision of the First Level Complaint Review Committee is binding unless the member appeals to Capital BlueCross Second Level Complaint Review Committee. Second Level Complaint Review A member or a member s representative has sixty (60) days from receipt of the decision of the First Level Complaint Review Committee to request a second level complaint review. A member or a member s representative may request a second level complaint review by contacting Capital BlueCross Customer Service Department at the following address and telephone numbers: Capital BlueCross Second Level Complaint PO Box 779518 Harrisburg, PA 17177-9518 Toll-free: 1-800-543-7101 TDD: 1-800-242-4816 Capital BlueCross will acknowledge receipt of the request for a second level complaint review in writing. Capital BlueCross acknowledgment letter will explain the procedures to be followed during the second level complaint review and the member s rights. The member or the member s representative may request the aid, at no charge, of a Capital BlueCross employee in preparing the complaint for review by the Second Level Complaint Review Committee. The Second Level Complaint Review Committee, consisting of three (3) or more individuals who did not participate in the first level complaint review and are not directly supervised by any previous decision makers, will review the second level complaint. At least one-third of the committee membership will include individuals who are not employed by Capital BlueCross or a related subsidiary or affiliate. The member will receive fifteen (15) days advance written notice of the date and time scheduled for the second level complaint review, and the member and the member s representative may participate in the second level complaint review. The Second Level Complaint Review Committee will complete its review of the complaint (and any written data or other information submitted by the member or the member s representative in support of the complaint) and reach a decision within forty-five (45) days of receipt of the request for a second level complaint review. Capital BlueCross will notify the member in writing within five (5) business days of the committee s decision. The notice will include the basis for the decision and the procedures to file an appeal of the decision. The decision of the Second Level Complaint Review Committee will be binding unless appealed by the member. External Complaint Review A member has fifteen (15) days from receipt of notice of the decision of Capital BlueCross Second Level Complaint Review Committee to appeal to the Pennsylvania Insurance Department or the Pennsylvania Department of Health. The member s appeal must be in writing unless the member requests to file the appeal in another format. The appropriate addresses for filing written appeals of second level complaint review decisions are: C3/cf/contracts/vision 9
Bureau of Consumer Services Pennsylvania Insurance Department 1209 Strawberry Square Harrisburg, PA 17120 1-717-787-2317 Toll-free: 1-877-881-6388 Bureau of Managed Care Pennsylvania Department of Health Health and Welfare Building, Room 912 7th and Forster Streets Harrisburg, PA 17120 1-717-787-5193 Toll-free: 1-888-466-2787 Fax: 1-717-705-0947 Pennsylvania AT&T Relay Services: 1-800-654-5984 In the case of an external complaint review, Capital BlueCross will transmit records from the first and second level complaint reviews to the appropriate agency within thirty (30) days of a document request from the Pennsylvania Insurance Department or the Pennsylvania Department of Health, as appropriate. The member and Capital BlueCross may submit additional materials for review and consideration. Each party shall provide to the other copies of any additional documents provided to the agency. An attorney or another representative may represent the member in the external complaint review. Filing a Grievance How to File a Grievance A member, a member s authorized representative, or a health care provider with the member s written consent can dispute a determination that service or care was not medically necessary and appropriate by filing a grievance. A grievance must be filed with Capital BlueCross within one hundred eighty (180) days of receipt of the adverse benefit determination. Written grievances should be mailed to the following address: Capital BlueCross First Level Grievance Review PO Box 779518 Harrisburg, PA 17177-9518 Members who are unable to file a written grievance due to a disability or language barrier may file an oral grievance by calling Capital BlueCross Customer Service Department, toll-free, at 1-800-543-7101. The Customer Service phone line supports calls from hearing-impaired members through the use of a TDD machine at 1-800-242-4816 or by other hearing-impaired enabling technology. Customer Service supports non-english speaking callers through the availability of translators. When filing the first level grievance, the member, the member s representative, or the health care provider filing the grievance with the member s written consent should include all necessary supporting information, including medical records. C3/cf/contracts/vision 10
Capital BlueCross will acknowledge receipt of the grievance in writing. Capital BlueCross acknowledgement letter will explain that Capital BlueCross classifies the dispute as a grievance and will provide the appropriate address and telephone number for the member to contact the Pennsylvania Department of Health to contest Capital BlueCross classification of the dispute as a grievance. The acknowledgment letter will also describe the grievance process and the member s rights. Members may, but are not required to, appoint a representative to act on their behalf at any time during the grievance process. Members must contact Customer Service to obtain an Authorized Representative Designation Form. If a health care provider files a grievance with the member s written consent, the written consent must include the elements required by the Pennsylvania Department of Health [See 31 Pa. Code 9.706(e)]. A provider, having obtained written consent from the member, shall have ten (10) days from receipt of a written denial from Capital BlueCross and any decision letter from a first or second level review upholding Capital BlueCross decision to notify the member of his/her intention not to pursue the grievance. The member, the member s representative, or the health care provider filing the grievance with the member s written consent may review information related to the grievance and may submit additional material for Capital BlueCross consideration. Capital BlueCross will provide copies of relevant information to the member, the member s representative, or the health care provider filing the grievance with the member s written consent free of charge, upon request. The member or the member s representative may request the aid, at no charge, of a Capital BlueCross employee in preparing the grievance. The member, the member s representative, or the health care provider filing the grievance with the member s written consent may specify the remedy being requested. First Level Grievance Review Capital BlueCross will investigate all grievances. A First Level Grievance Review Committee consisting of one or more persons selected by Capital BlueCross who did not previously participate in the adverse benefit determination and who is/are not directly supervised by the original decision maker will review the grievance. The committee will include a licensed physician, or, where appropriate, an approved licensed psychologist, in the same or similar specialty that typically manages or consults on the health service or care in dispute. The First Level Grievance Review Committee will follow the time frames identified below: Pre-Service Grievances Post-Service Grievances Capital BlueCross First Level Grievance Review Committee will reach a decision and notify the member, the member s representative, and the health care provider filing the grievance with the member s consent of the decision within thirty (30) days of receipt of the grievance. Capital BlueCross First Level Grievance Review Committee will reach a decision within thirty (30) days of receipt of the grievance and will notify the member, the member s representative, and the health care provider filing the grievance with the member s consent within five (5) business days of the decision. C3/cf/contracts/vision 11
The decision notice will include the basis and clinical rationale for the decision as well as the process to file a request for a second level review of the decision. The decision of the First Level Grievance Review Committee is binding unless the member appeals to Capital BlueCross Second Level Grievance Review Committee. Second Level Grievance Review A member, the member s representative, or the health care provider filing the grievance with the member s consent has sixty (60) days from receipt of the decision by the First Level Grievance Review Committee to request a second level grievance review. A member, the member s representative, or the health care provider filing the grievance with the member s consent may request a second level grievance review by writing to: Capital BlueCross Second Level Grievance Review PO Box 779518 Harrisburg, PA 17177-9518 Capital BlueCross will acknowledge receipt of the request for a second level grievance review in writing. This acknowledgment letter will explain the procedures to be followed during the second level grievance review and the member s rights. The member or the member s representative may request the aid, at no charge, of a Capital BlueCross employee in preparing the grievance for review by the Second Level Grievance Review Committee. The Second Level Grievance Review Committee, consisting of three or more individuals who did not participate in the first level review and are not directly supervised by the previous decision makers, will review the second level grievance. This review will include a licensed physician, or, where appropriate, an approved licensed psychologist, in the same or similar specialty that typically manages or consults on the health service or care in dispute. The member will receive fifteen (15) days advance written notice of the date and time scheduled for the second level grievance review, and the member, the member s representative, and the health care provider filing the grievance with the member s written consent may participate in the second level grievance review. The Second Level Grievance Review Committee will complete its review of the grievance (and any written data or other information submitted by the member, the member s representative, or the health care provider filing the grievance with the member s written consent) and reach a decision within forty-five (45) days of receipt of the request for a second level grievance review. Capital BlueCross will notify the member in writing within five (5) business days of the committee s decision. The decision notice will include the basis and clinical rationale for the decision. The notice will also provide an explanation of how to request an external grievance review. The decision of the Second Level Grievance Review Committee will be binding unless appealed by the member. External Grievance Review A member, the member s representative, or the health care provider filing the grievance with the member s written consent has fifteen (15) days from receipt of notice of the second level grievance review decision to request an external grievance review. C3/cf/contracts/vision 12
Written requests for external grievance reviews must be mailed to: Capital BlueCross External Grievance Review PO Box 779518 Harrisburg, PA 17177-9518 All necessary supporting information, including medical records, should accompany the request for an external grievance review. If a health care provider files the request for an external grievance with the member s written consent, the health care provider must provide the name of the member and a copy of the member's written consent along with the external grievance review request. The health care provider and Capital BlueCross will each place in escrow an amount equal to one-half of the estimated costs of the external grievance review. Providers who file grievances with the member s written consent will be liable for all fees and costs related to the external grievance process if Capital BlueCross determination is upheld. Capital BlueCross will acknowledge receipt of the request for an external grievance review in writing within five (5) business days. Capital BlueCross acknowledgment letter will notify the Pennsylvania Department of Health, the member, the member s representative, and the health care provider filing the grievance with the written consent of the member that a request for an external grievance review has been filed. Capital BlueCross acknowledgment letter will also request that the Pennsylvania Department of Health assign a certified external review organization. A certified external review organization that is not affiliated with Capital BlueCross or a related subsidiary or affiliate will conduct the external grievance review. Capital BlueCross will notify the member, the member s representative, or the health care provider filing the grievance with the member s written consent after a certified external review organization has been assigned to review the grievance. Capital BlueCross, the member, the member s representative, or the health care provider filing the grievance with the member s written consent has the right to object to any certified external review organization assignment within seven (7) business days. Within fifteen (15) days of receipt of the request for external grievance review, Capital BlueCross will forward to the assigned certified external review organization written documentation regarding the grievance and will provide the member, the member's representative, or the health care provider filing the grievance with the member's written consent with a list of the documents forwarded to the certified external review organization. Within fifteen (15) days of receipt of Capital BlueCross acknowledgment letter, the member, the member's representative, or the health care provider filing the grievance with the member's written consent may supply additional information to the certified external review organization for consideration in the external grievance review. The member, the member's representative, or the health care provider filing the grievance with the member's written consent must provide copies of this additional information to Capital BlueCross. The assigned certified external review organization will review the grievance and issue a written decision within sixty (60) days of the filing of the request for an external grievance review. The decision shall be subject to appeal to a court of competent jurisdiction within sixty (60) days of receipt of notice of the external grievance decision. C3/cf/contracts/vision 13
Expedited Complaints or Grievances Expedited Internal Review A member may request from Capital BlueCross an expedited internal review at any stage of the complaint or grievance process if: 1. the member s life, health, or ability to regain maximum function would be placed in jeopardy by delay occasioned by following the time frames applicable to the standard complaint or grievance process. 2. in the opinion of a physician with knowledge of the member s condition, the member would be subject to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. To request an expedited internal review, the member must provide Capital BlueCross with a written certification from the member s health care provider that the member s life, health, or ability to regain maximum function would be placed in jeopardy by the delay occasioned by the standard complaint or grievance process or the member would be subjected to severe pain without the requested treatment. The health care provider s certification must include the clinical rationale and facts to support the health care provider s opinion. Upon receipt of the health care provider s certification, Capital BlueCross will provide an expedited internal review. If the member does not submit such a certification from their physician, Capital BlueCross will review the member s case to determine if it meets the criteria listed above to be considered an expedited internal review. The member, the member s representative, or the health care provider filing an expedited grievance with the written consent of the member may start the expedited internal review process by calling Capital BlueCross Customer Service Department, toll-free, at 1-800-543-7101. Requests for expedited internal reviews should be made by telephone to avoid any mail delays. A Capital BlueCross review committee will review the expedited complaint or grievance. The member, the member s representative, or the health care provider filing the expedited grievance with the member s written consent may participate in the review. If time and distance do not permit attendance at the review committee meeting, Capital BlueCross may hold the meeting by telephone. Members and their health care providers are responsible for providing information to Capital BlueCross to enable Capital BlueCross to conduct an expedited review. Capital BlueCross will conduct an expedited internal review and issue its decision within fortyeight (48) hours of receipt of the member's request for an expedited internal review accompanied by the health care provider's certification, as required. Capital BlueCross decision notice will state the basis for the decision, including any clinical rationale, along with the procedure for requesting an expedited external review. The decision of the Capital BlueCross expedited internal review committee is binding unless the member requests an expedited external review. C3/cf/contracts/vision 14
Expedited External Review The member, the member s representative, or a health care provider filing an expedited grievance with the member s written consent may request an expedited external review within two (2) business days of receiving notice of Capital BlueCross expedited internal review decision by calling Capital BlueCross Customer Service Department, toll-free, at 1-800-543-7101. Requests for expedited external reviews should be made by telephone to avoid any mail delays. Within twenty-four (24) hours of receipt of the request for an expedited external review, Capital BlueCross will notify the Pennsylvania Department of Health to request the assignment of a certified external review organization. Within one (1) business day of receiving the request from Capital BlueCross, the Pennsylvania Department of Health will assign a certified external review organization that is not affiliated with Capital BlueCross or a related subsidiary or affiliate. Capital BlueCross will transfer a copy of the member s case file to the assigned certified external review organization on the next business day. The certified external review organization will issue a decision within two (2) business days of receiving the member s case file. C3/cf/contracts/vision 15