Members Can Appeal Coverage Decisions

Members Can Appeal Coverage Decisions

Members Can Appeal Coverage Decisions
Internal Appeals

Blue Cross and Blue Shield of Illinois (BCBSIL) has an internal claims and appeals process that allows you to appeal decisions about paying claims, eligibility for coverage or ending coverage.

Please check “adverse benefit determination” in your benefit booklet for instructions.

External Appeals

If your internal appeal is denied, in some cases you may request an external review. External review is an option for denials for services that were not medically necessary or were clinically unproven.

As a BCBSIL HMO member, you may have these types of denials examined by external, independent reviewers. The independent review organization is not associated with your health plan. There is no charge for requesting the review.

We will send you information reminding you that independent, external review of coverage is available every year. We mail the information to members who do not have fax, email or internet access.

Call the customer service number on your member ID card if you have questions about the external review process.

Find Tools and Resources

Log in to Blue Access for MembersSM, our secure member website, for a personalized search experience based on your health plan and network. Learn more about your benefits and gain access to member services. Get coverage details, access resources and tools, and more. You can also find doctors in your network, get an ID card, and sign up for text or email notifications, tips and reminders.

Originally published 10/14/2019; Revised 2020, 2022, 2023

  • Peer to Peer BCBS also denied.  Had appointment with primary care and she formulated letter in support with various reasons that stated I met all the criteria required after the peer to peer now waiting on appeal.  I have hear that these tend not to go well.  Looks like BCBS will avoid meeting their obligations to subscribers.  I am so disappointed.  I been forced to wait though out this process 1st 6 months of requirements by the Cleveland Clinic (6/4/2023 - November 29, 2023) to get Denied.  Then for peer to peer (December 30, 2023) of which I have received nothing in writing about results.  Just a email from Cleveland Clinic saying it was again denied.  I let them know I wanted the Appeal that they submitted in January and now I will not have a result for another month 2/17/24.  In the mean time still getting fatter went to annual appointment primary care 1/8/2023 and it is official BMI 41.2 with high blood pressure, joint issues and overall just not feeling well.  OSU primary care wrote letter supporting me having procedure and yet  BCBS still continues to make me wait.  I was told decision will be available on a Saturday 2/17/2023 and that too seems a little off to me to make decision available on a Saturday.  In mean time I am held hostage to this appeal process.  I was told by BCBS I could yet appeal again to another outside agency if I am unhappy with their findings.  This sucks and this should not be the health care insurance companies treat not just their insured clients but the hospital that support their plans.  This is so out of wack.  If somone qualifies for treatment by their provider (my doctors) and through the terms of my health care policy (BCBS) I should not have to go through this mountain of red tape and still yet possible be denied the care in which I pay for every month.   This sucks.

  • Why am I held hostage to appeal process when I meet the criteria for this procedure under the terms of the contract with BCBSil.  I am very upset that I am not able nor is my provider able to provide me a service I am entitled to and meet the criteria under my policy.  This is so wrong.