More General Information on Georgia Health Insurance

Grievances and Appeals

• What is the procedure for lodging a grievance against a provider or against the Claims Administrator?
• • Fax the details of your grievance to 1-877-868-7950 or call the customer service number on your ID care. Your inquiry should be resolved within 21 calendar days.
• How do I express dissatisfaction regarding a denial of services?
• • As a Participant, you have a right to express dissatisfaction and to expect fair resolution of your issues. The Claims Administrator has established the inquiry, formal complaint, and appeal process to be pursued any time you are displeased with any aspect of services rendered.
  • • Inquire - You may call customer service at the phone number listed on your ID card. Describe your concern and we will make every effort to respond within 21 calendar days.
    • Formal Complaint - If you are not satisfied with our response, you may file a formal complaint in writing to BCBSGa, PO Box 9907, Columbus, GA 31908. Fax the details of your request, along with supporting documentation, to 1-877-868-7950 or you may call customer service number on your ID card.
    • Final Internal Appeal - If you still disagree with the determination, you will be able to file one last appeal that will be presented to a Voluntary Appeal Panel Committee. The request must be in writing and you must have exhausted the first level appeal.
• What if waiting for you to decide on my appeal would harm my health?
• • If your condition is of an emergent or urgent nature, you, along with your Physician will decide on the most appropriate treatment plan.
• My Explanation of Benefits (EOB) says I received services that I did not have. What should I do?
• • Call the customer service number located on your member ID card. Our associates will review your EOB and fix any errors that may have occurred.

Eligibility Appeals
If you need to appeal an eligibility decision, please write to:

State Health Benefit Plan
Membership Correspondence Unit
P.O. Box 38342
Atlanta, GA 30334

Be sure to send an appeal form, which is available through your personnel/payroll office, website address www.dch.ga.gov, or directly from the SHBP @ 1-800-610-1863. Please be sure to include the enrolled Participant's SSN.

Terms of Your Coverage
The Plan provide the benefits described in this SPD Booklet only for eligible Participants. The health care services are subject to the limitations, exclusions, Copayments, and percentage payable requirements specified in this SPD Booklet. Any group BCBSHP contract or certificate which you received previously will be replaced by this Plan.

Benefit payment for Covered Services or supplies will be made either directly to the Network Hospital (or Network Facility), the Network Physician or to you depending upon whether services were rendered by a Network or Non-Network Provider.

The Plan is not responsible for any Injuries or damages you may suffer due to actions of any Hospital, Physician or other person.

In order to process your claims, the Claims Administrator or the Plan Administrator may request additional information about the medical treatment you received and/or other group health insurance you may have. This information will be treated confidentially.

An oral explanation of your benefits by an Employee of the Claims Administrator, Plan Administrator or Plan Sponsor is not legally binding.

Any correspondence mailed to you will be sent to your most current address. You are responsible for notifying the Plan Administrator or the Claims Administrator of you new address.