Health Care Quality Concerns Form
Complete and submit this online fillable form. Your concerns and comments are important to us. If you have concerns about a clinic, doctor or other health care professional, we’d like to hear from you.
Fraud Alert: caller targets Regence members
Regence offers advice for protecting yourself
October 22, 2007, updated November 2, 2007
We recently learned that several of our members have received suspicious phone calls from a caller claiming to be from Regence. Members were asked for either their bank account or credit card information.
Regence is committed to protecting our members' privacy. As such, we never call members to request this type of financial information over the phone in a "cold call" style.
However, members would receive this type of call from Regence if they have elected to deduct their premium from their bank account and we require information to complete their application. In this case, the interaction would have been initiated by the member. In addition, members are also offered the opportunity to send in a new form, should they not wish to provide financial information over the phone.
Members should contact Regence or their benefits administrator if they suspect they have received a questionable phone call. In the meantime, there are things you can do to protect yourself if you receive these types of calls:
- Do not provide credit card or bank account information to the caller.
- If you have received a call and provided financial information, we recommend that you cancel the credit card(s) immediately or contact your bank to flag your bank accounts to monitor suspicious activity. You can also request free credit reports online to monitor your credit for possible identity theft. Be sure to use the official, centralized web site: www.annualcreditreport.com.
- You can also contact your local police department. Regence will fully cooperate with any law enforcement agency to assist in their investigation.
Questions?
If you have any questions or concerns, please contact us.
Agent Bonus/Commission Notice
If you have a broker or agent, they may receive bonuses, commissions, administrative services, or other compensation, from Regence. Incentives may be based on any of several factors, including the size of group business, the products you buy, your broker or agent's volume of business with Regence and the other services your agent or broker provides to you. These incentives may have an indirect impact on your rates. For more information, please contact your broker or agent.
Traditional and Managed Care Appeal and Grievance Process
What is an Appeal?
An “Appeal” is a written or oral request from a Member or, if authorized by the Member, the Member’s Representative, to change a previous decision made by Regence BlueShield of Idaho concerning:
- Access to health care benefits, including an adverse determination made pursuant to utilization review,
- Claims payment, handling or reimbursement for health care services, or
- Matters pertaining to the contractual relationship between a Member and the plan, or
- Other matters as specifically required by State law or regulation.
Who is a "Member"?
“Member” is the enrolled employee or contract holder or his/her enrolled dependent.
Who is a "Member Representative"?
"Member Representative" is any authorized representative of the Member.
For most appeals there are two Levels of review. In some cases there is available a third level appeal for determination of medical necessity and experimental/investigational procedures.
Level 1 – Appeal (Complaint/Grievance/Reconsideration)
- Regence BlueShield of Idaho must receive an appeal (complaint/grievance) within 180 days of the initial claims denial. If received an acknowledgment receipt is sent within seven (7) days
- Regence BlueShield of Idaho staff will investigate the issue, including all aspects of the clinical case.
- The member receives a written decision within thirty (30) days of receipt of the appeal (complaint/grievance). If more time is needed, the member will be notified of that within the same thirty (30) days. No more than 15 additional days will be used.
- If the decision is not in the member’s favor, Regence BlueShield of Idaho will let the member know that a further appeal (the second level of the process) may be submitted and must be received within one hundred and eighty (180) days of the first level decision.
Level 2 – Appeal (Internal Appeal)
- Regence BlueShield of Idaho receives the appeal and acknowledges receipt within seven (7) days.
- Regence BlueShield of Idaho staff gathers documentation related to the case and the case is reviewed by the health plan’s three-member Internal Appeal Panel.
- The member receives a written decision within thirty (30) days of submission of the appeal and within five (5) working days of the decision being made. The exceptions to this time frame will be:
- If the appeal involves denial of care as investigational, this will be decided within 20 working days, and
- Appeals involving denial of pre-authorization of care will be decided within 14 days (or up to 30 days if notice of need for delay is given to the member).
- If the decision is not in the member’s favor, Regence BlueShield of Idaho will let the member know if a third level appeal is available. When available the appeal must be received within one hundred and eighty (180) days of the second-level decision.
Level 3 – Appeal (External Appeal) This level is only for medical necessity and experimental/investigational procedures.
- Regence BlueShield of Idaho receives the appeal and acknowledges receipt within seven (7) days.
- Regence BlueShield of Idaho staff gathers documentation related to the case and delivers it to an independent physician review organization (IRO) within three (3) working days of receipt of the appeal. NOTE: The IRO is not controlled by Regence.
- The IRO makes a decision within fifteen (15) days of receipt of the appeal, unless additional time is needed, the IRO will notify the member within the same 15 days of this need. No more than five (5) additional days will be used.
- The member will receive a written decision.
Appeals Forms
Fill out the appeals form (PDF) and mail to the address below.
For members requesting to have their physician appeal on their behalf, the member must complete the following form:
Mail with your signature to:
Regence BlueShield of Idaho
Attn: Appeal Coordinator
P O Box 1106
Lewiston, ID 83501
In order to verify requests for information made by Regence BlueShield of Idaho, please contact our Customer Service department at (208) 746-2671 or toll-free at 1 (800) 632-2022. If you want additional information regarding privacy at Regence BlueShield of Idaho, please refer to our Notice of Privacy Practices at www.regence.com/legal/index.jsp.
Additional information about preventing identity theft may be found on the Federal Trade Commission Web site at www.ftc.gov/bcp/edu/microsites/idtheft.
How to Protect Yourself from Identity Theft
Fraudulent Telephone Calls and E-mails Seek to Capture Consumer Information
Consumers should stay alert for telephone calls or spam e-mails that claim to come from well-known companies. The exact scam may vary, but usually the telephone call or e-mail will claim that there is a problem with the consumer’s account and that they need to confirm the consumer’s personal information
Do not give out personal information on the phone, through the mail or over the Internet unless you have initiated the contact or are sure you know who you're dealing with. Identity thieves may pose as representatives of insurance companies, banks, Internet service providers (ISPs) and even government agencies to get you to reveal your Social Security Number, mother's maiden name, account numbers and other identifying information. Before you share any personal information, confirm that you are dealing with a legitimate representative of the organization. You can check the organization's Web site as many companies post scam alerts when their name is used improperly.