Customer Service
A member called to ask about a prescription refill. The pharmacy staff sighed loudly, interrupted them, and said, “I don’t have time for this right now.”
What is a grievance related to rude behavior? (Customer Service)
A member calls upset because they were charged an extra $150 after their visit, even though they paid their copay.
What is a grievance related to being billed an additional amount above the member responsibility? (Provider / Facility Billing Complaint)
“My mailbox is full of brochures and letters from the plan—I didn’t ask for this.”
What is a grievance related to excessive mail such as brochures and advertising materials? (Excessive Calls/Mail From Plan/Plan Vendors)
A member called about her local pharmacy where she receives her prescription. “The pharmacy was dirty and didn’t look safe.”
What is a grievance related to pharmacy was unclean? (Pharmacy Issue)
“I called in because it took way too long for me to get my plan documents.”
What is a grievance related to length of time to receive materials? (Complaint About Fulfillment Polices)
A member called three times about a billing error. Each time, they were told someone would follow up. No one ever did.
What is a grievance related to unresolved issues and/or not receiving a callback as expected ? (Customer Service)
“My appointment was canceled because I didn’t confirm within 24 hours.”
What is a grievance related to a policy regarding appointment cancellations within 24 hours? (Complaint About Provider / Facility Office Policies)
“The pharmacy keeps asking me to pay even though I’m in the payment plan.”
What is a grievance related to pharmacy incorrectly requiring payment? (MPPP)
“I called in because the pharmacy is too far away, and I can’t get there easily.”
What is a grievance related to distance to the pharmacy? (Pharmacy No In-Network/Distance to Pharmacy)
Member called to ask about her ID card. “I changed providers last month, but my new ID card still shows my old doctor. This could cause claim denials—why wasn’t this updated?”
What is a grievance related to failure to update and send correct plan materials after a provider change? (They Did Not Receive The Requested Materials)
A member was told by a representative that a specialist visit was covered. Weeks later, they received a $300 bill and were told the rep gave incorrect info.
What is a grievance related to misinformation? (Customer Service)
"The provider barely explained my treatment plan and rushed through the visit.”
What is a grievance related to inadequate attention or time spent by the provider? (Provider / Facility Experience)
"I paid my premium, but the plan says they never received it.”
What is a grievance related to the plan did not credit their payment? (Lost Payment)
Member called to ask about paperwork she received from his local pharmacy. “They told me I need to fill out extra forms just to get my prescription.”
What is a grievance related to requiring certain paperwork for prescription service?
“I called in because I requested my plan materials in Braille two months ago, but they sent me regular print twice. I’m concerned this violates accessibility requirements.”
What is a grievance related to failure to provide materials in the requested accessible format despite multiple requests? (Complaint About Fulfillment Polices)
A member struggled to understand the advocate due to a strong accent and rapid speech. They left the call confused about their benefits.
What is a grievance related to difficulty understanding the advocate? (Customer Service )
“The HouseCalls practitioner showed up at 5:00 PM when the appointment window is 12:30 PM - 4:30 PM.”
What is a grievance related to HouseCalls practitioner arriving late or outside the appointment window? (Provider / Facility Experience)
“I called in because my medication is covered, but not the way I expected—it’s costing me more.”
What is a grievance related to a medication covered but not the way the member prefers? (Prescription Drug Benefit)
“I called in because my EOB shows a medication I never requested or received.”
What is a grievance related to a medication billed without member consent? (Fraud, Waste or Abuse)
“I called in because the new UCard design is confusing—the Rx BIN and PCN numbers are missing, and the barcode doesn’t scan at the pharmacy.”
What is a grievance related to missing prescription information and barcode issues on the ID card? (Member Material Format / Design)
A member spent 50 minutes on a call trying to confirm their eligibility for a routine service, with long pauses and repeated holds.
What is a grievance related to long call times? (Customer Service)
“I arrived 10 minutes early, but they said I needed to be there 30 minutes before.”
What is a grievance related to a policy requiring arrival a certain amount of time before appointment? (Complaint about Provider / Facility Office policies)
“I called in because my bill shows $300 instead of the $150 I was told when I enrolled.”
What is a grievance related to the plan incorrectly calculated what is owed? (MPPP)
A member called because she saw information on the news about a medication she takes. “I called in because I never got the recall notice for my medication, and now I’m worried I took something unsafe.”
What is a grievance related to not receiving or unclear recall notices? (Pharmacy Operations/Policies/Correspondence)
“I just received a late notice about my premium payment even though I paid my premium on time. How does the plan handle timing conflicts like this?"
What is a grievance related to a timing issue where premium bill and payment crossed in the mail causing incorrect late notices? (Complaint About Fulfillment Polices)