Pennsylvania General Information and Internal Plan Review: Pennsylvania distinguishes between grievances and complaints, and has separate procedures for each type of problem. A grievance is any request to have a review of a denial of a covered health service on the basis of medical necessity or appropriateness. A complaint relates to most other problems regarding health plan operations, quality of care or service, contract exclusions, or covered benefits.
Problems are initially filed with the health plan, which usually decides if the issue is a grievance or a complaint. If grievances are not satisfactorily resolved in their two-step process, they can be appealed for review by an independent utilization review organization. If complaints are not satisfactorily resolved in a two-step process with the plan, they may be appealed to either the Department of Health or the Insurance Department.
The External Grievance Appeal Process: Whom to contact: | Your health plan | Who can appeal: | You or your provider (with written permission), or your authorized representative
If your provider files the grievance, he or she will be responsible for the cost of the review if the denial is upheld by the independent utilization review organization. | What you can appeal: | Denials of coverage for services the health plan determines are not medically necessary or appropriate. | When you can appeal: | After denial for coverage has been appealed through the second level of the health plan’s internal process, you must appeal within 15 days from receipt of health plan’s decision. | What to send: | - Enrollee’s name, address, and phone number
- Name of health plan
- Enrollee ID number
- Copy of denial letter
- Brief description of the problem
- Any additional material that supports your position.
| What you must pay: | Up to $25 | What will happen: | - The health plan will notify the state.
- The state will assign your case to an independent utilization review organization.
- The review organization will evaluate your case and provide written notice to you, the health plan, and the Department of Health.
| When you will get a decision: | In about 60 days | In urgent situations: | If delay will jeopardize your life, health, or ability to regain maximum function, you should work with your plan to facilitate an expedited review, which will result in a 48-hour turn-around time. Expedited reviews are also processed at the state level within two working days. |
How to Get More Information: Complaints or Grievances: Bureau of Managed Care, 888-466-2787
Complaints: Pennsylvania Insurance Department, 877-881-6388
www.health.state.pa.us (follow link to “Provider,” and then to “Managed Care”) Information updated as of 2-12-2005 |
