This area is provided as a resource to our members for notices, policies and procedures that affect their coverage.
Compare even more detailed quality measures with different providers
Disclosure Notices
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.
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.
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 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 BlueShield 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 BlueShield 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) 458-3523. If you want additional information regarding privacy at Regence BlueShield, 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.
