Types of Grievances
an expression of dissatisfaction about a sales agent, regardless of whether the person is a broker, field agent, or Telesales agent.
Sales
true or false is this a grievance: confused; don’t understand, why is this…; what does this mean; etc..
false: upset; angry; frustrated; did not receive; canceled appointment; could not schedule; didn’t show up; refuse; rude; (this is a grievance)
Transportation did not pick the member up for her appointment and she had to reschedule the appointment for another day
QOC
prospective member A member who is calling before their effective date.
An expression of dissatisfaction with the manner in which the plan provides health care services regardless of whether any remedial action can be taken.
Part C
FYI: 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.
statements may include: upset; angry; frustrated; did not receive; canceled appointment; could not schedule; didn’t show up; refuse; rude; etc..
Grievance
true or false this is correct documentation: member stated she was advised by her PCP dr Brown she could not be seen because she did not pay her past due bill
False: member stated she was advised by her PCP Dr Michael Brown 1212 Jumble Branch Ln Houston TX 23243 898.555.0000 because she had a past due bill
the driver was 2 ours late picking up the member from her appointment to take her home
Verbal Grievance
active or current member: A member who is calling on or after their effective date, or before or on their termination date.
All Complaint Types. (Verbal, QOC, ODAG, CD, Sales)
A decision about Part D payments or benefits to which a member believes he or she is entitled to.
Coverage Determination
FYI: A request to provide or pay for a Part D drug.
Tiering exception request.
Formulary exception request.
A decision about the amount of cost sharing for a Part D drug.
General complaints about medication coverage status or costs are grievances
Coverage Determination
true or false this is proper to add to your documentation- the driver was a big dummy
false: only document facts not opinions
no one showed up to pick the member up for her appointment but her neighbor took her so she did not miss her appointment
Verbal Grievance
legal representative: Non-attorney callers with legal documentation of authority. Includes Power of Attorney, Conservator, Guardian, Parent of an unemancipated minor- under age of 18 ,Trustee, Administrator, and Executor. This authority must be listed on the member's account.
All complaint types.
FYI: Attorney calls should be handled as directed in HIPAA Caller Type - Attorney
A general request or question about the plan, without an expression of dissatisfaction.
Inquiry
type of grievance wherein the member’s care or ability to receive care was or could have been affected
Quality of Care
true or False is this proper documentation
Member is dissatisfied that they ordered their Warfarin (through OptumRx) on 01/01/2019 and was advised that it would arrive by 01/24/2019 and they still have not received it as of 02/03/2019.
true
the driver yelled at the member and was rude to him because he was slow walking to the van
verbal grievance
House Calls Representative
Verbal Grievances, as relayed to them by the member. The member is not required to be on the phone for Advocates to document the Verbal Grievance.
If the member believes that they are being held responsible for a Part C service or portion of a cost share amount that should be the health plan's responsibility.
Appeals
request for coverage from OON provider or non covered benefit
Organization Determination
True or False Documentation correct: the driver smelled like alcohol
True the fact is member smelled alcohol
verbal grievance
Provider Definition: A medical, dental, or vision professional.
Pre-Service Appeals, Part C and D, for standard or expedited requests FYI: Providers can submit pre-service appeals on behalf of a member for a standard or expedited requests. Appeals, Part C and D, are handled by individual and employer group member service advocates. Do NOT transfer to the provider line.
when the member requests a coverage determination to have the Part D medication covered by the plan or covered at a lower cost and the request is denied. This is not the same as a rejection at the pharmacy. Adverse coverage determinations are issued OptumRx or A&G.
Adverse Coverage Determination