GRIEVANCE ACKNOWLEDGEMENT

June 15, 2024

Member Name:                                                                                                                                                                                  Meshake Djuma

Member ID:                                                                                                                                                                                         000911777445

EAA ID:                                                                                                                                                                                                                                                                                                                                                                  533499930

For help to translate or understand this letter, please call 1-877-860-2837 or TDD/TTY 711.

Dear Amisi Djuma:

Blue Cross Community Health Plans, offered by Blue Cross and Blue Shield of Illinois, received your grievance on June 14, 2024 for a bill you received for date of service May 7, 2024 for $83.  We will review your grievance and send a written decision to you on or before September 12, 2024.

If you have questions, please call us at 1-877-860-2837 or TDD/TTY 711.

Sincerely,

Shawanda C.

Blue Cross Community Health Plans

Appeals and Grievance Department

BCCHP Non Discrimination Statement

Blue Cross Community Health Plans is provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association.