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Participant Complaint, Grievance, and DHS Fair Hearing Process

PA Health & Wellness recognizes that there are times when participants and providers may not be satisfied with a matter handled by PA Health & Wellness.  Participants and providers 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.

Consent For Provider to File a Complaint or Grievance for Participant Form (PDF)

A Participant Complaint is a dispute or objection regarding a Provider or the coverage, operations, or management policies of PA Health & Wellness, which has not been resolved by PA Health & Wellness and has been filed with PA Health & Wellness or with DOH (Dept. of Health) or PID (PA Insurance Dept.).

PA Health & Wellness allows the Participant at least 60 days to file a Complaint from the date of the occurrence of the issue being complained about, or the date of the Participant’s receipt of notice of the plan’s decision.

A Participant Complaint includes, but is not limited to:

  • A denial because the requested service or item is not a Covered Service
  • A failure of PA Health & Wellness to meet the required time frame for providing a service or item
  • A failure of PA Health & Wellness to decide a Complaint or Grievance within the specified time frames
  • A denial of payment by PA Health & Wellness after a service has been delivered because the service or item was provided without authorization or by a provider not enrolled in the MA Program
  • A denial of payment by PA Health & Wellness after a service or item has been delivered because the service or item provided is not a Covered Service for the Participant
  • A denial of a Participant’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Participant financial liabilities. The term does not include a Grievance.

A Grievance is request to have PA Health & Wellness or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a Covered Service.

A Grievance may be filed regarding PHW’s decision to:

  1. Deny, in whole or in part, payment for a service/item
  2. Deny or issue a limited authorization of a requested service/item, including a determination based on the type or level of service/item;
  3. Reduce, suspend, or terminate a previously authorized service/item
  4. Deny the requested service/item but approve an alternative service/item
  5. Deny a request for a Benefit Limit Exception (BLE).

* This term does not include a Complaint.