While the health plan member services departments may resolve many issues, if you are not satisfied with the resolution, or if you think the issue is not being resolved quickly enough, you may also file a formal “grievance with the plan.”
Every plan must have a grievance and appeals procedure to handle non-medical issues. This includes complaints related to billing problems, benefit coverage issues and issues regarding dissatisfaction with providers or quality of care provided. Some grievances can be filed over the phone, while others must be filed in writing. The health plan will tell you how to file a grievance and what your rights are in the grievance process.
Patients may also have questions relating to the denial of a specific medical treatment, even though the type of treatment may be covered (for example, a plan’s benefits may provide for treatment of cancer, but not stage-one clinical trials). These types of questions are considered utilization review decisions. Your rights concerning decisions on medical issues are covered in more detail in the “utilization review standards” and the Independent External Appeal sections.
For non-medical, contractual issues, every plan’s grievance procedure must include:
- A multi-lingual, accessible toll-free phone line, available at least 40 hours a week. Answering machines may be used during off hours, but your call must be returned within one business day.
- A standard process for filing grievances and appeals and, in certain circumstances, filing verbal grievances.
- Notice of a member’s right to have a representative in the grievance process.
- A process for providing members with a written description of the procedures required to file an appeal when a plan denies a request for service.
- The time-frames for responding to members, including notice of the plan’s receipt of the grievance and grievance determinations.
- Standard time-frames for making a decision on a grievance can be as long as 45 days. But if there is a significant risk to your health, the plan must act within 48 hours.
- The methods for designating qualified reviewers for each grievance, including at least one health care professional for matters of a clinical nature.
- In addition to having processes for filing a grievance, all plans must have a method for making a decision on any and all grievances received.
The following criteria apply to the appeals of grievance determinations:
- Members are provided 60 business days to appeal a grievance decision.
- Clinical determinations must be made by qualified health care professionals not involved with the original decision.
- Non-clinical matters require qualified personnel at a higher level than those who made the initial determination.
- There must be a formal notice of appeals determinations detailing reasons for the determination and the clinical rationale.