You have the right to voice concerns about your health care.
You may file a grievance if:
You are concerned about the type of care you are getting. You are concerned about the quality of the care you are getting. You have other concerns about us or your provider. If you are unhappy or concerned about the quality of care you received, you can file a grievance to be referred to our Medical Peer Review Committee. You may file a grievance at any time.
You may appeal:
An appeal is when you ask for a review of an adverse benefit determination. An adverse benefit determination is when we:
- Deny or limit a service you want.
- Reduce, suspend or terminate payment for a service you are getting.
- Fail to authorize a service in the required time.
- Fail to respond to a grievance in the required time
You must complete an appeal before you can request a State Fair Hearing.
You may request a State Fair Hearing. A State Fair Hearing is like a trial in court. The hearing is your chance to tell a third party why you disagree with the agency. You must request a fair hearing within 120 calendar days (an additional 3 calendar days is allowed for mailing) of decision the notice of the adverse benefit determination. For more information on the fair hearing process, please call Member Services at 1-877-542-9238.