This area is provided as a resource to our members for notices, policies and procedures that affect their coverage.
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.
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.
Clinical Practice Guidelines
The guidelines are available online. They'll tell you what we expect your provider to do for you if you have particular health conditions. We base these guidelines on the consensus of medical research currently available. Note that procedures and services mentioned in the guidelines do not guarantee coverage.
Member Appeals Process Information
Regular appeal process
- First Step: The Complaint
What the member must do:
You, or someone representing you, tell us, your health plan (Regence BlueShield), about your complaint in writing or verbally within 180 days of receiving something in writing from us - such as an Explanation of Benefits or letter denying a pre-authorization request. Explain what you're dissatisfied with based on a previous decision or action by us. You may give us written materials supporting your complaint. If you or your provider is asking Regence BlueShield to reconsider a previously denied pre-authorization, your provider may be able to talk directly with a Medical Director.
What Regence BlueShield does:
A Member Service Specialist with contract benefits, enrollment and claims processing expertise accepts and logs the complaint and notifies you of receipt within five days. The representative, working together, as needed with a Medical Director, medical services, legal or communication departments, investigates the complaint, gathers facts and prepares a "complaint package" of detailed information. Based upon that package, the representative makes a decision, records it in writing and sends a decision to you within 30 days of first receiving your complaint. That decision must be understandable, describe how you may appeal the decision and the timing required, list the people at our health plan who helped make the decision, state the facts and refer to supporting documents. After receiving this response, you may ask us to reconsider by appealing the decision (See Second Step).
- Second Step: Internal Appeal
What the member must do:
Tell us you want to appeal our decision (based on your complaint) in writing or verbally within 180 days of receiving the decision notification of your complaint. You may give us written materials supporting your appeal and you are invited to appear in person.
What Regence BlueShield does:
The appeal coordinator (Registered Nurse), working as part of a "panel", accepts and logs your appeal and notifies you within five days that it was received. The panel consists of Company representatives including the appeal coordinator, an administrative representative who is a Member Service Specialist with contract benefits, enrollment and claims processing expertise and a Medical Director. Panel members are new to the case and have not been involved in any previous decision made regarding your original complaint.
This panel may also coordinate with medical services, legal and communication departments with the Company. The Medical Director may also confer with an independent physician with medical training related to your appeal. The appeal coordinator investigates the complaint, gathers facts and prepares an "appeal package" of detailed information. The panel, using this package and appropriate resources, makes a decision on the appeal and records it in writing. The decision is sent to you by certified mail within 30 days of first receiving your appeal. You'll get the decision within 20 days if it's about an investigational medical procedure and within 14 days if it's about a service that your provider wants for you but needs approval from our Company to perform. The written decision must be understandable, describe how you may request another appeal and the timing required, list the people at Regence BlueShield who helped make the decision, state the facts and refer to support documents.
- Third Step: External Appeal
What the member must do:
Tell us you want to appeal our decision (based on your complaint) in writing or verbally within 180 days of receiving the decision notification of your complaint.
What Regence BlueShield does:
An appeal coordinator accepts and logs your appeal and notifies you within five days that it was received. The coordinator gathers all facts and supporting documents together with the previous internal appeal packet, and delivers it to an Independent Review Organization (IRO) within three days of receiving your request for an external appeal. An IRO, made up of physicians not associated with our Company, with medical training in the area of your appeal, reviews your case and makes a decision. These physicians are new to the case and have not been involved in any previous decisions made about your complaint or internal appeal. The IRO makes a decision, records it in writing and sends it to us. Then, we notify you by certified mail within 20 days of receiving your initial appeal request. Our letter to you must be understandable, describe the next appeal level, if any, and the timing required, list the independent physicians who made the decision, state the facts and refer to support documents.
Expedited appeal process
For members who need a faster process because of a life-threatening medical condition, there is an expedited appeal process. In this case, you go through an Internal Appeal process similar to the one outlined above. The difference is the reviewing "panel" is new to the case, and they make a decision in one working day or 72 hours, whichever is less after you tell us that you want an expedited appeal. If you aren't satisfied with that decision, you may ask for an expedited, second level appeal similar to the External Appeal process described above. The difference is the IRO makes a decision in one working day or 72 hours, whichever is less after you tell us that you want another expedited appeal. Non-binding mediation may also be a final, optional step in the expedited appeal process. We will tell you if non-binding mediation is an option for you if the second level expedited appeal is denied.
