Agent Experience
Member says an agent was rude / talked over them
Standard Grievance
Why? Complaint about a behavior.
Standard research required from another team
Next Step: Apologize, acknoledge impact to the mm, help the mm w their reason for calling in, file grievance
Member says the denial letter was confusing/misleading
FCR Grievance
Why? Complaint about communication clarity is a service complaint.
FCR bc we educate and provide clarity to mm, nothing else can be done to resolve the information being confusing to the mm.
Next step: File grievance for communication concern; offer appeal steps if they want the decision reviewed.
Member says their copay for their prescription was higher than expected and wants you to "fix it"!
Not a grievance
Why? Claim dispute
Next step: Education on coverage and copay, possible Tier or formulary exception Rework or Appeal
Member says there are no available in-network providers taking new patients near them; they’re angry.
It Depends!
Why? Access-to-care frustration would be a complaint about a service = FCR Grievance bc we can resolve by locating in network provider and/or exception/coverage determination process.
Request for approval is a coverage decision issue = exception/coverage decision is a different lane
Next step: Determine where the frustration is and route as applicable. Attempt provider search, determine if an exception/request coverage decision process is needed.
Member says the website/app is broken and they can’t access documents
It's a grievance!
Why? Service barrier impacting member experience/ online services we proivde
Standard if the mm's website issue cannot be resolved on the call and requires another team to investigate & fix the website.
FCR if you help the mm gain access to the docuemtns they are needing
Next Step: Apologize/Acknowledge impact, Assist MM best you can, file grievance
Member says they were on hold 45 minutes and transferred 3 times
Standard Grievance
Why? Complaint about a service, access to customer service.
Standard bc another team has to research the why/validity behind the hold and transfers
Next step: Apologize & Acknowledge impact, assist mm, file grievance.
Member says they requested communications in Spanish but all letters are coming in English and they are frustrated
FCR Grievance
Why? Complaint about communications with the service we proivde
FCR bc we can change their settings to Spanish
Next Steps: Apologize, Acknowledge impact, reoslve the issue, file grievance
Member is upset that their claim was denied.
Not a grievance
Why? Denial dispute = Appeal/possible coverage determination
Next Step: Provide education/reason for denial, possible rework/coverage determination required
The doctor’s office says you messed up the authorization. The Provider office told the member “the plan caused the delay,” and the member is frustrated and wants it fixed.
It Depends!
Why?
Service/runaround complaint = Standard grievance bc another team has to reseach why the mm is getting the runaround
Change/approve the decision = coverage determination/appeal
Next step: Clarify what outcome they want, then route accordingly.
Member says transportation was late and they missed an appointment
Standard Grievance!
Why? Complaint about a vendor not providing a service we supply with our plan.
Standard bc another team needs to research why the ride was late and provide a responce to the mm.
Next Step: Apologize & Acknowledge impact, offer asistacne in reschduling appointment and ride, file grievance
Member says they were promised a callback and it never happened
Standard Grievance
Why? Complaint about failure to meet a service commitment.
Standard bc another team needs to research why the comitment was not kept.
Next step: Apologize & Acknwledge impact, assist MM file grievance.
Member rcvs LEP penalty letter. MM is upset that they owe a penalty and states the ywere never told they needed to have prescription coverage.
Not a Grievance!
Why? We cannot file grievances on complaints about a LEP penalty.
When Can we file a grievance regarding LEP's?
If the agent input the infomration wrong which caused the mm to have a penalty.
Member got a bill from a provider and believes the bill is not correct, mm states "This bill is too high, the plan did something wrong and I need this corrected”
Not a grievance --> start out as an inquiry
Why? This is usually a claim/EOB explanation first; classify after facts.
Next step: Review claim/EOB details, explain what happened and provide any options.
File a grievance only if the complaint is about service handling (runaround, misinformation, delays, rude treatment).
Member says, “You keep telling me it’s under review and nothing is happening”
It Depends!
Why? Delay in service handling or lack of follow-through can be a grievance. Standard bc it requires another team to research the lack of follow through.
Delays tied to a formal decision timeline belong in the determination/appeal lane.
Next step: Identify what kind of case it is first (claim, prior auth, appeal, request, etc.)
Then either (a) file a grievance for service delay/poor handling or (b) follow process for coverage determination/appeal
Member does not want to use designated Vendor to get their hearing aids. Member stated he can get them for less at Costco.
FCR Grievance!
Why? Complaint about a vendor requirment with a service our plan offers.
FCR bc we provide benefits in full, offer to transfer over to Nations hearing to learn more or make appointment. No one else can change this, no other research is needed.