Grievance & Appeals

Filing a Grievance

A “grievance” means any dissatisfaction expressed orally or in writing by or on the member’s behalf regarding:

  • the availability, delivery, appropriateness or quality of health services;
  • the handling or payment of claims for health care services; or
  • matters pertaining to the contractual relationship between a member and the health plan administrator; and for which the member has a reasonable expectation that action will be taken to resolve or reconsider the matter that is the subject of the dissatisfaction.

The grievance procedure begins when a member or the member’s representative contacts their Health Plan Administrator and registers a grievance that includes an explanation detailing their grievance. The following steps will be taken upon receipt of a grievance:

  • the Health Plan Administrator will document receipt of the grievance, including the date received, nature of the complaint and the ultimate resolution;
  • the Health Plan Administrator will investigate and resolve the grievance in an expeditious manner; and
  • the Health Plan Administrator will notify the member or the member’s representative by mail of the disposition of the grievance. If the grievance is denied in whole or in part, the member will be notified of the right to appeal the Health Plan Administrator’s decision.

Appealing a Grievance Decision

The appeals procedure begins when a member or the member’s representative sends written notification to the Health Plan Administrator at the address below or via the web site at requesting review of a grievance decision. The written notification must be mailed within 180 days from the date of the letter notifying the member of the right to appeal. The member or member’s representative must include an explanation of the reason why the grievance decision should be reconsidered. The Health Plan Administrator will mail written acknowledgment of the appeal to the member or member’s representative within five (5) business days after the appeal is received. The acknowledgement will include the date the appeal was received as well as who to contact at the Health Plan Administrator regarding the appeal. The Health Plan Administrator utilizes an appeals committee composed of individuals who have sufficient experience, knowledge and training to appropriately resolve an appeal. The committee will consult as needed with physicians specializing in the services performed or other experts to resolve the appeal. The appeals committee will investigate and resolve the appeal in an expeditious manner. The member will be notified by mail of the resolution of the appeal within ten (10) days after the appeal is filed. Written notification of the appeal resolution will include:

  • a statement of the appeal committee’s understanding of the appeal;
  • a full description of the claims and appeals procedures;
  • a description of the resolution reached by the appeals committee and the contract basis or medical rationale for the resolution stated in clear terms;
  • a reference to the evidence or documentation used as a basis for the resolution;
  • disclosure of the names of medical professionals consulted during the claims process; and
  • patients must have access to all documents and records relevant to their claim or appeal, regardless of whether the plan says it relied on the materials