Grievances
A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.
Grievances about quality – You are unhappy with the quality of care, such as the care you received in the hospital.
Grievances about privacy – You think that someone did not respect your right to privacy, or shared information about you that is confidential.
Grievances about poor customer service – A health care provider or staff was rude or disrespectful to you.
Grievances about physical accessibility – You cannot physically access the health care services and facilities in a provider’s office.
Grievances about waiting times – You are having trouble getting an appointment, or waiting too long to get it.
Grievances about cleanliness – You think the clinic, hospital or provider’s office is not clean.
Grievances about communications from us – You think the written information we sent you is too difficult to understand.
Coverage Determinations &Appeals
The process for asking for coverage determinations and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment.
What is a coverage determination?
A coverage determination is an initial decision your Interdisciplinary Team (IDT), PHP Care Complete FIDA-IDD Plan, or an authorized specialist makes about your benefits and coverage or about the amount PHP Care Complete FIDA-IDD Plan will pay for your medical services, items, or drugs. Your IDT, PHP Care Complete FIDA-IDD Plan, or your authorized specialist is making a coverage determination whenever it decides what is covered for you and how much PHP Care Complete FIDA-IDD Plan will pay. Authorized specialists include dentists, optometrists, ophthalmologists, and audiologists.
The PHP enrollee, enrollee’s representative, or the provider on behalf of the enrollee, has the right to request a pre-service organization determination (prior authorization).
Coverage Determination Time Period
- Members who contact the call center requesting coverage determination (including exceptions requests) will receive the following turnaround:
- 24 hours for expedited grievances
- 72 hours for standard requests
What is an appeal?
An appeal is a formal way of asking us to review a decision made by your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist and change it if you think a mistake was made. For example, your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist might decide that a service, item, or drug that you want is not covered. If you or your provider disagree with that decision, you can appeal.
Note: You are a member of your IDT. You can appeal even if you participated in the discussions that led to the coverage determination that you wish to appeal.
How can we assist you?
Contact Partners Health Plan for current member assistance, to learn more about becoming a PHP member, or for general questions and inquiries.