Categorization
The correct Request Type for grievances related to the Late Enrollment Penalty (LEP).
What is Part D?
What is a Coverage Determination?
The correct procedure for this issue: "My sales agent has been unreachable since he sold me the plan."
What is the Agent Misconduct Allegation Grievance Procedures?
Correct error code for this downscore: The EOC letter enclosure is not explained/referenced in the body of the resolution letter.
What is "Letter did not address all issues?"
The correct Category for grievances related to Coordination of Benefits (COB) issues.
What is Other?
"The provider I saw on this claim is a specialist, not an urgent care. I should have a $25 copay, not $45."
What is an appeal?
The correct procedure for this issue: "I was supposed to have a telehealth appointment with my therapist yesterday but they never called me."
What is Behavioral Health Access Grievance Procedures?
Correct error code for this downscore: As the case was not sent to NAL for investigation, there is no response from NAL to relay in the letter.
What is "Inaccurate resolution provided - Missing BP response?"
The correct Category for a complaint about how difficult and time-consuming it is to file an appeal.
What is Organization Determination & Reconsideration?
"I saw an OON podiatrist while I was on vacation. Please reimburse me for what I spent OOP."
What is an Org Determination?
The correct procedure for this issue: "I should've received my ID card months ago when I joined. Without it, I have no proof I'm enrolled in this plan."
What is Miscellaneous Grievance Procedures?
The correct Category for a complaint about the Spending Card IVR.
What is Provider Customer Service?
"Please reinstate my dental allowance. I attempted to get dentures, but they didn't fit and I never took them home but the claim paid."
What is an Org Determination?
The correct procedure for this issue: "I received a letter that my service was approved, but it's confusing and I don't know what service it's talking about."
What is Medical Clinical Intake Team (CIT) Grievance Procedures?
The correct Category for a complaint regarding a member who had to see a Nurse Practitioner instead of a Doctor.
What is Quality of Care?
"My auth for an MRI was denied due to not being medically necessary, but my doctor says I need this. Please reconsider the authorization."
What is an appeal?
The correct procedure for this issue: "I am deaf but my PCP does not offer American Sign Language interpreters/accommodations."
What is Discrimination Grievance Procedures?