Grievance Category
Description
100
What grievance category would I use for the hold music being too loud?

Customer Service / Technology

100

What is the definition of a Part C grievance? 

An expression of dissatisfaction with the manner in which the plan provides health care services regardless of whether any remedial action can be taken. Expressions of dissatisfaction involving an organization determination or an appeal should not be classified as a grievance. Grievances may include complaints regarding timeliness, appropriateness, access to, and/or setting of a provided health service, procedure or item.

200

What grievance category would I use for my provider being late? 

Provider/Facility/Hospital

200

What is the definition of a coverage determination? 

  • If the member believes the health plan has charged a different cost-sharing amount than the person thinks he or she should have to pay.

    Example: disputes about the copayment amount.

  • The member disputes the amount he or she is asked to pay for a drug and the basis is the plan's TrOOP calculation.
300

What grievance category would I use if the member ID letters are too small?

Fulfillment 

300

What is the definition of an organization determination?

A decision about Part C payment or benefits, or the discontinuation of health services that the member believes he or she is entitled to. It also applies to the failure of the health plan to arrange or pay for services, or to provide the member with a notice of denial in a timely manner, when the delay could adversely affect the member's health.

*In general, an organization determination must be made before a member can file an appeal.

400

What grievance category would I use if my broker gave me incorrect information?

Sales Agent or Broker

400

What is the definition of a part C appeal? 

When a member, their representative (if appropriate) or their physician requests that an adverse organization determination be reevaluated. This includes: review of denied claims, delays in providing, arranging for, or approving health care services, if those delays cause adverse health effects to the member, or on Part C cost sharing disputes.

500

What grievance category would I use if SafeRide was late for picking me up?

NONE! Transfer to SafeRide. 

500

What is the definition of a quality of care grievance? 

QOC complaints occur when services received by a member from a medical provider / facility or pharmacy are inadequate or substandard in quality.

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