Complaint, Grievance, and DHS Fair Hearing Process
PA Health & Wellness recognizes that there are times when participants may not be satisfied with a matter handled by PA Health & Wellness. Participants, or their authorized representative, have the right to file a complaint related to that matter. The Complaint and Grievance Procedures will describe the process to file a Complaint, Grievance or Fair Hearing along with the response and resolution timeframes and the complainant (grievant)’s rights during the process.
A complaint is an expression of dissatisfaction communicated by a complainant, orally or in writing, about any matter related to PA Health & Wellness, a network contracted provider or the services they have received. As provided by 42 C.F.R. §438.400, possible subjects for complaints include, but are not limited to:
- The quality of care of services provided
- Aspects of interpersonal relationships such as rudeness of a provider or employee
- Failure to respect the participant’s rights.
When PA Health & Wellness denies, decreases, or approves a service or item different than the service or item you requested because it is not medically necessary, you will get a notice telling you PA Health & Wellness’s decision. A Grievance is when you tell PA Health & Wellness you disagree with PA Health & Wellness’s decision.
In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something PA Health & Wellness did or did not do. These hearings are called “Fair Hearings.” You can ask for a Fair Hearing after PA Health & Wellness decides your First Level Complaint or decides your Grievance.
You may file a complaint or grievance via phone, fax or mail:
- Call 1-844-626-6813 and TTY 1-844-349-8916
- Fax 1-844-873-7451
- Write and mail to PA Health & Wellness, Attention Complaint and Grievance Unit, 300 Corporate Center Drive, Camp Hill, PA 17011
FIRST LEVEL COMPLAINT PROCESS
PA Health & Wellness permits a participant or participant’s representative, which may include the participant's provider, with proof of the participant's written authorization.
If the Complaint disputes the failure of PA Health & Wellness to decide a Complaint or Grievance within the specified timeframes; challenges the failure to meet the required timeframes for providing a service/item; disputes a denial made for the reason that a service/item is not a covered benefit; disputes a denial of payment after the service(s) has been delivered because the service/item was provided without authorization by a provider not enrolled in the Pennsylvania Medicaid Program; or disputes a denial of payment after a service(s) has been delivered because the service/item provided is not a covered benefit for the participant, the participant must file a Complaint within Sixty (60) days from the date of the incident complained of or the date the participant receives written notice of the decision. For all other Complaints, there is no time limit for filing a Complaint.
The first level Complaint review committee will complete its review of the Complaint as expeditiously as the participant's health condition requires, but no more than thirty (30) days from receipt of the Complaint, which may be extended by fourteen (14) days at the request of the participant.
PHW will send a written notice of the first level Complaint decision to the participant, participant's representative, if any, service provider and prescribing PCP, if applicable, within five (5) Business Days from the first level Complaint review committee’s decision. The participant or the participant's representative may file a request for a Second Level Complaint review (“Second Level Complaint”) within Sixty (60) days from the date the Member receives written notice of PA Health & Wellness first level Complaint decision.
SECOND LEVEL COMPLAINT PROCESS
Within Two (2) Business Days of receipt of the Second Level Complaint, PA Health & Wellness will send the participant and participant's representative, if any, an acknowledgment letter.
The decision of the Second Level Complaint Review Committee will be based solely on the information presented at the review. The Second Level Complaint Review Committee will complete the Second Level Complaint Review within forty-five (45) days from receipt of the participant's Second Level Complaint.
PA Health & Wellness will send a written notice of the second level Complaint decision, to the participant or participant’s representative, if any, within five (5) Business Days from the Second Level Complaint Review Committee’s decision.
The participant or the participant's representative may file a request for an external review of the Second Level Complaint decision with either the DOH or PID within fifteen (15) days from the date the participant receives the written notice Second Level Complaint decision.
The Participant or the Participant’s representative, with may include the Participant’s Provider, with proof of the Participant’s written authorization for the representative to be involved and/or act on the Participant’s behalf, may file, in writing, a request for an External Review of the Second Level Complaint decision with either DOH or PID within fifteen (15) days from the date the Participant receives PHW’s Second Level Complaint decision.