Verify Benefit Coverage
We strongly encourage members to ask their provider to check Regence's website or call us to verify benefit coverage before services are provided. Members may also call Regence for any questions about whether a service is a covered benefit.
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.
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 BlueCross BlueShield of Oregon 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.
Member Appeals Process
When members have concerns about the processing of a claim or other action by Regence BlueCross BlueShield of Oregon and wish to have it reviewed, they or their representative may appeal within 180 days of receiving our written determination—such as an explanation of benefits or a letter denying a pre-authorization request. Appeals may be made either verbally or in writing.
All appeals are reviewed by appropriate Regence BlueCross BlueShield of Oregon staff who were not involved in previous determination(s) and are responded to in writing. For members who need a faster process and whose appeal qualifies, there is an expedited appeal process. Following the internal process, an independent, external review may be available for certain matters. The appeal process varies by type of plan in order to comply with state and federal law. Details are available in the member's benefit book.
If you have any questions, please contact our Customer Service department toll-free at 1 (800) 365-3155. If you want additional information regarding privacy at Regence BlueCross BlueShield of Oregon, please refer to our Notice of Privacy Practices at www.regence.com/legal/notice-of-privacy-practices.jsp.
Download a printable copy of our appeal process notice (PDF) that includes government resources to turn to if you are not satisfied with our assistance, or if you have additional questions about this notice or your appeal rights.
Pre- and Post-Sale Disclosures for Clark County, WA
Disclosures for Regence BlueCross BlueShield of Oregon members living in Clark County, Washington.
- Pre-Sale Disclosure Statement (PDF)
- Post-Sale Disclosure Statement: Health Care Patient Bill of Rights (PDF)
Consumer Privacy Notice (PDF)
Explanation of Agent and Broker Commissions
November 21, 2005
The Regence Group and affiliate companies offer benefit plans and services through independent life and health insurance agents and/or brokers. Agents and/or brokers are independent contractors—they are not employees of Regence. Agents and/or brokers must be licensed in the state(s) in which they do business. As a health carrier, we pay agents and brokers commissions for selling our plans and services.
Independent health insurance agents with whom we do business enter into a contract with us, agreeing to fairly represent our plans and services, abide by our privacy policy and requirements, and adhere to our expectations of performance and professionalism in dealing with members who chose us as their health carrier. An independent life and health insurance agent who is paid a commission by the insurance carrier is representing the carrier and the products and services that carrier offers. Most independent health insurance agents represent a variety of insurance companies, which allows them to provide their clients with comparison information to aid in benefit purchase decisions. Most agents and/or brokers are also an excellent resource for questions regarding coverage, and may act as an advocate for their client when questions arise.
It's important to us that you understand the role that your agent or broker plays in the health care and the health benefits industry. In Oregon and Southwest Washington where we offer our plans and services, independent life and health insurance agents, agencies and brokers perform important services for you as their client. While they are not employees of our company, they are an important part of our sales and service team.
Agents, agencies and brokers with whom we do business are paid commission for selling and renewing the plans we offer. Our agent commission is part of administrative expenses, which factor into the premium rates we charge for individual policyholders, small group policyholders, and most large employer group policyholders. Large employers and their agents or brokers may negotiate direct compensation fees, in lieu of commissions. You are not required to include an 'agent of record' on coverage you purchase with us. We charge the same premium rates for members who elect not to use an agent as we charge for those who do.
In addition to commissions, agents and/or brokers may receive bonus, administrative service fees or other compensation from us. The compensation we pay may include non-cash compensation, such as incentives based on the amount of business they place with us, the products they sell, their overall volume of clients that they maintain with our company, and/or the services they provide to our insured members. Like all costs included in our administrative expenses, the cost of these incentives may have a direct or indirect impact on premium rates.
- Individual and Small Group Agent Commission
- We pay a percentage of the overall premium as commission compensation to our agents. Our premium rates for these plans include administrative expenses that include agent/broker commissions. Regulation requires us to 'pool' our plan pricing by the type of plan. Individual plans are a 'pool', small employers with 2-25 employees are another 'pool' and employers with 26-50 employees are another 'pool.'
- Large Group Agent Commission
- Large employer group health plans may choose to negotiate the commission rate or agent/broker fees as they negotiate coverage, benefits and pricing. These negotiated amounts are disclosed in our proposals of coverage, to assure the employer is aware of all charges and fees associated with the purchase of our plans and services.
- Disclosure
- Your broker or agent provides a valuable service, and we want you to know that Regence BlueCross BlueShield of Oregon may at times provide incentives for that service. Brokers or agents may receive bonuses, commissions, administrative service fees or other compensation, including non-cash compensation, from Regence BlueCross BlueShield of Oregon. These incentives may be based on any of several factors, including the size of group business, the products you buy, your broker's or agent's volume of business with Regence and the other services your agent or broker provides to you. At times, these incentives may have an indirect impact on your rates. Your broker or agent can provide you with more information about incentives.
