Bluegrass Family Health provides a thorough process to address Covered Person complaints and appeals. These administrative remedies must be exhausted before legal remedies are sought.

If you have an inquiry or complaint regarding your benefits or claims you may contact a Customer Service Representative at (859) 269-4475 or (800) 787-2680. We will respond to your complaint within fifteen (15) calendar days. An example of a complaint would be "I have trouble getting into my doctor's office in a timely manner." We track and trend all Covered Person complaints for quality improvement purposes.

A Covered Person, authorized person or Provider acting on behalf of the Covered Person may initiate an internal appeal. An appeal is a request for review of an Adverse Determination or a coverage denial as defined below. An internal appeal may also be initiated if an insurer or its designee fails to make a utilization review determination and provide written notice within the timeframes as specified in KRS 304.17A-607.

"Adverse Determination" means a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a Covered Person are:

1. Not medically necessary, as determined by the insurer, or its designee or experimental or investigational, as determined by the insurer, or its designee; and
2. Benefit coverage is therefore denied, reduced, or terminated.

Adverse determination does not mean a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a Covered Person are specifically limited or excluded in the Covered Person's health benefit plan.

"Coverage Denial" means an insurer's determination that a service, treatment, drug, or device is specifically limited or excluded under the Covered Person's health benefit plan. A request for an internal appeal must be submitted within sixty (60) days of receipt of a denial letter. To initiate an internal appeal, please forward the following information to the attention of the Appeals Coordinator, Bluegrass Family Health, 651 Perimeter Drive, Suite 300, Lexington, Kentucky 40517:

• The initial denial letter
• The number of claims in question
• The date(s) of service
• A summary of any previous communication you have had with Bluegrass Family Health regarding this denial
• Any additional pertinent medical information

A Kentucky licensed Physician who did not participate in the initial review and denial will review internal appeals of Adverse Determinations. Covered Persons, authorized person, or Provider may request a board eligible or certified Physician in the appropriate specialty or subspecialty area to conduct the internal appeal relating to an Adverse Determination.

The Covered Person, authorized person, or Provider acting on behalf of the Covered Person will be notified of the internal appeal decision within thirty (30) calendar days of receipt of the internal appeal request.

An expedited internal appeal process is available if the Covered Person is hospitalized or, in the opinion of the treating Provider, a review under a standard time frame could, in the absence of immediate medical attention; result in any of the following:

1. Placing the health of the Covered Person or, with respect to a pregnant woman, the health of the Covered Person or the unborn child in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of a bodily organ or part.

In the case of an expedited appeal the insurer or its designee shall render a decision not later than three (3) business days after the receipt of the request for an expedited internal appeal. An expedited appeal may be requested orally and followed up by an abbreviated written request by contacting Customer Service at (859) 269-4475 or (800) 787-2680 and requesting the Appeals Coordinator, or in writing by sending the request to the Appeals Coordinator, Bluegrass Family Health, 651 Perimeter Drive, Suite 300, Lexington, Kentucky 40517.

Any additional pertinent information may be submitted for consideration during the internal appeal process. Once the internal appeal process has been completed, but prior to the initiation of the external review process, new clinical information regarding the Covered Person's internal appeal shall be provided to the insurer. The insurer shall then have five (5) business days from the date of receipt of the new information to render a decision based on the new information. The sixty (60) day timeframe to initiate an external review of an Adverse Determination shall not begin until the determination on the new information that has been rendered.

If the Covered Person is dissatisfied with the internal appeal decision or if the internal appeal decision is not rendered within the required time frame, the Covered Person may request a review of a "coverage denial" by the Kentucky Office of Insurance, Division of Health Insurance Policy and Managed Care, P.O. Box 517, Frankfort, Kentucky 40602.

The Kentucky Office of Insurance may uphold the Plan's decision, or direct the Plan to cover the service, or afford the Covered Person the opportunity for an external review if a medical issue requires resolution.

If the Covered Person, authorized person, or Provider is dissatisfied with the internal appeal decision or if the internal appeal decision is not rendered within the required time frame or the insurer and Covered Person agree to waive the internal appeal process, the Covered Person may request an external review of an "Adverse Determination" or Coverage Denial which requires resolution of a medical issue by an independent review entity (IRE) certified by the Kentucky Office of Insurance.

The external review process can be initiated by a Covered Person, authorized person, or Provider acting on behalf of and with the consent of the Covered Person within 60 days after exhausting the internal appeal process if the following conditions are met:

1. The insurer, its designee, or agent has rendered an Adverse Determination;
2. The Covered Person has completed the insurer's internal appeal process, or the insurer has failed to make a timely determination or notification as set forth in KRS 304.17A-619(2). The insurer and the Covered Person may however, jointly agree to waive the internal appeal requirement;
3. The Covered Person was eligible on the date of service or, if a prospective denial, the Covered Person was enrolled and eligible to receive covered benefits under the health benefit plan on the date the proposed service was requested; and
4. The entire course of treatment or service will cost the Covered Person at least $100 if not covered by the insurer.

An external review of an "Adverse Determination" shall not be afforded if:

1. The subject of the Covered Person's adverse determination has previously gone through the external review process and the independent review entity found in favor of the insurer; and
2. No relevant new clinical information has been submitted to the insurer since the independent review entity found in favor of the insurer.

If a dispute arises between an insurer and a Covered Person regarding the Covered Person's right to an external review, the Covered Person may file a complaint with the Kentucky Office of Insurance at the address listed above. The Department shall render a decision within five (5) days of receipt of he complaint.

The insurer will be responsible for the cost of the external review. The Covered Person will, however, be responsible for a $25 filing fee to be paid to the IRE, which may be waived in case of financial hardship or refunded if the IRE finds in favor of the Covered Person. The insurer will assign external reviews to IREs on a rotating basis such that the insurer does not utilize the same IRE for two consecutive reviews.

Requests for external review shall be submitted to External Review, Appeals Department, Bluegrass Family Health, 651 Perimeter Drive, Suite 300, Lexington, Kentucky 40517. If you have questions regarding the external review process please contact Customer Service at (859) 269-4475 or (800) 787-2680 and ask to speak with the Appeals Coordinator.

As part of the request, the Covered Person shall provide to the insurer a consent authorizing the IRE to obtain all necessary medical records from both the insurer and any Provider utilized for review purposes regarding the decision to deny, limit, reduce, or terminate coverage. All medical records involved in the external review process shall be deemed confidential and shall not be subject to KRS 61.805-61.850 and KRS 61.870-61.884.

The IRE must render a determination within twenty-one (21) calendar days of receipt of the request for external review. An extension of up to fourteen (14) calendar days may be allowed if the Covered Person and the insurer are in agreement.

An expedited external review process is available if the Covered Person is hospitalized or, in the opinion of the treating Provider, a review under a standard time frame could, in the absence of immediate medical attention; result in any of the following:

1. Placing the health of the Covered Person or, with respect to a pregnant woman, the health of the Covered Person or her unborn child in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of a bodily organ or part.

In the case of an expedited external review the IRE shall render a decision within twenty-four (24) hours from receipt of all information required from the insurer. An extension of up to twenty-four (24) hours may be allowed if the Covered Person and the insurer agree. An expedited external review may be requested orally and followed up by an abbreviated written request by contacting Customer Service at (859) 269-4475 or (800) 787-2680 and requesting the Appeals Coordinator, or in writing by sending the request to External Review, Appeals Department, Bluegrass Family Health, 651 Perimeter Drive, Suite 300, Lexington, Kentucky 40517.