Appeals and Grievances

For Capital Blue Cross HMO and Capital Blue Cross PPO Members

You can file a grievance if you’re unhappy with our service, plans or providers.

You can also appeal a denial of payment, eligibility or other decision.

• Member Appeal and Grievance Form
• Reference Guide for Filing an Appeal
• Reference Guide for Filing a Grievance
• Request for Medicare Prescription Drug Determination
• Request for Redetermination of Medicare Prescription Drug Denial
• Medicare Complaint Form
• Waiver of Liability Form for Appeals from Non-Par Providers

Please see your Capital Blue Cross PPO evidence of coverage or Capital Blue Cross HMO evidence of coverage for details.

Appointing a Representative

To select a representative, complete the Appointment of Representative form. Your representative will be able to act for you. You and the representative must sign the form. We will need a copy of the signed form.

Obtaining a Coverage Decision

Members of Capital Blue Cross PPO and Capital Blue Cross HMO can ask for a coverage decision about a service or drug. To request a rushed coverage decision, please contact Capital Blue Cross HMO at 800.779.6962 or Capital Blue Cross PPO at 866.987.4213 (TTY: 711). Standard coverage decisions must be in writing.

Please send these requests to:

Capital Blue Cross HMO Organizational Determinations (or) 
Capital Blue Cross PPO Organizational Determinations 

PO Box 779970 
Harrisburg PA 17177-9970 
Fax: 1.888.456.2449

Prime Therapeutics 

Attention: PA Department 
2900 Ames Crossing Road
Eagan, Minnesota 55121
Fax: 1.800.693.6703

Obtaining Data on Appeals and Grievances

Members of Capital Blue Cross PPO and Capital Blue Cross HMO can receive a description of the plans’ total number of appeals and grievances received and how these cases were resolved.

Contact Capital Blue Cross PPO and Capital Blue Cross HMO by phone or in writing.

Capital Blue Cross HMO Appeals and Grievances (or) 
Capital Blue Cross PPO Appeals and Grievances 

PO Box 779970  
Harrisburg, PA 17177-9970

Need Help?

If you need help filing an appeal, you can call member services at 800.779.6962 if you are a Capital Blue Cross HMO member, or 866.987.4213 (TTY: 711) if you are a Capital Blue Cross PPO member.