Grievances

What is a grievance (complaint)?

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

• Do you believe that someone did not respect your privacy or shared information about you that you feel should be confidential?
• Has someone been rude or disrespectful to you?
• Do you feel that you were waiting too long on the phone or when getting medical care?
• Do you believe we have not given you a notice that we are required to give?
• If you have asked us to give you a “fast response” for an organizational determination or an appeal, and we have said we will not, you can make a complaint.
• If you believe our plan is not meeting deadlines for giving you an organizational determination or an answer to an appeal you have made, you can make a complaint.

You must file a grievance within 60 days from the date of the event that led to the complaint. Grievances are reviewed on an individual basis and we will resolve the grievance as quickly as your health status requires. If you call us with a complaint, we may be able to give you an answer on the same phone call. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Expedited or fast grievances will be responded to within 24 hours if the grievance is related the plan’s refusal to make a fast coverage organization determination or reconsideration and you haven’t received the medical care yet. We will address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.

How to contact us when you are making an appeal or a complaint:

Hours of Operation: From October 1 through March 31, hours are 8 a.m. to 8 p.m., seven days a week. During this time period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8 a.m. to 8 p.m., Monday through Friday. During this time period on Saturdays, Sundays and federal holidays, calls are handled by our voicemail system. We will return calls the next business day.

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