Participant Complaint, Grievance, and DHS Fair Hearing Process

PA Health and 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 and 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 participantmust file a Complaint within forty-five (45) days from the date of the incident complained of or the date the participantreceives 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 participantor the participant's representative may file a request for a second level Complaint review (“second level Complaint”) within forty-five (45) days from the date the Member receives written notice of PA Health & Wellness first level Complaint decision.

If the Complaint disputes the failure of PA Health and Wellness to provide a service/item or to decide a Complaint or Grievance within specified time frames or disputes a denial made for the reason that a service/item is not a covered benefit, or disputes a denial of payment after a 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 may file a request for a DHS Fair Hearing within thirty (30) days from the mail date on the written notice of the first level Complaint decision.

Upon receipt of the second level Complaint, PA Health and 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 complete the second level Complaint review within forty-five (45) days from receipt of the participant's second level Complaint.

PA Health and Wellness will send a written notice of the second level Complaint decision, to the participant, participant's representative, if any, service Provider and prescribing provider, if applicable 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.

If the second level Complaint disputes the failure of PA Health and Wellness to provide a service/item or to decide a Complaint or Grievance within specified time frames or disputes a denial made for the reason that a service/item is not a covered benefit, or disputes a denial of payment after a 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 may file a request for a DHS Fair Hearing within thirty (30) days from the mail date of the written notice of PA Health and Wellness second level Complaint decision.

PA Health and Wellness will conduct expedited review of a Complaint at any point prior to the second level Complaint decision, if a participant or participant's representative provides PA Health and Wellness with a certification from the participant's provider that the participant's life, health or ability to attain, maintain or regain maximum function would be placed in jeopardy by following the regular Complaint process.

The certification must include the provider’s signature.  If the provider certification is not included with the request for an expedited review, PA Health and Wellness will inform the participant  that the provider must submit a certification as to the reasons why the expedited review is needed.

PA Health and Wellness will issue the decision resulting from the expedited review in person or by phone to the participant, the participant's representative, if the participant has designated one, and the participant's healthcare provider within either forty-eight (48) hours of receiving the provider certification or three (3)

Business Days of receiving the participant's request for an expedited review, whichever is shorter.

In addition, PA Health and Wellness will mail written notice of the decision to the participant, the participant's representative, if the participant has designated one, and the participant's healthcare providers within two (2) days of the decision.

The participant, or the participant's representative, with proof of the participant's written authorization for the representative to be involved and/or act on the participant's behalf, may file a request for an expedited external Complaint review with PHW within two (2) Business Days from the date the participantreceives the expedited Complaint decision.

The participant may file a request for a DHS Fair Hearing within thirty (30) days from the mail date on the written notice of the expedited Complaint decision.

PA Health & Wellness will permit a participant or the participant representative, which may include the participant’s provider, to file a Grievance either in writing or orally.

Participants will be given forty-five (45) days from the date the participant receives the written notice to file a Grievance.

PA Health & Wellness will send the participant and participant’s representative, if the participant has designated one, an acknowledgment letter. A participant who consents to the filing of a Grievance by a healthcare provider may not file a separate Grievance.  In order for the provider to represent the Participant in the conduct of a Grievance, the provider must obtain the written consent of the participant. A provider may obtain the participant’s written permission at the time of treatment. A provider may NOT require a participant to sign a document authorizing the provider to file a Grievance as a condition of treatment.

The first level Grievance review committee will complete its review of the Grievance as expeditiously as the participant’s health condition requires, but no more than thirty (30) days from receipt of the Grievance, which may be extended by fourteen (14) days at the request of the participant.

PA Health & Wellness will send a written notice of the first level Grievance decision, to the participant, participant’s representative, if the participant has designated one, service provider and prescribing PCP, if applicable, within five (5) Business Days from the first level Grievance review committee’s decision.

The participant or the participant’s representative, may file a request for a second level Grievance review (“second level Grievance”) within forty-five (45) days from the date the participant receives the written notice of first level Grievance decision. The participant may file a request for a DHS Fair Hearing within thirty (30) days from the mail date on the written notice of the first level Grievance decision.

Upon receipt of the second level Grievance, PA Health and Wellness will send the participant and the participant’s representative, an acknowledgment letter. 

The decision of the second level Grievance review committee will be based solely on the information presented at the review. The second level Grievance review committee will complete the second level Grievance review within forty-five (45) days from receipt of the participant’s second level Grievance.

PA Health and Wellness will send a written notice of the second level Grievance decision, to the participant, participant’s representative, if the participant has designated one, service provider and prescribing provider, if applicable, within five (5) Business Days of the second level Grievance review committee’s decision.

The participant or participant representative may file a request with PA Health and Wellness for an external review (“external Grievance review”) of the second level Grievance decision by a certified review entity appointed by the DOH. The request will be filed within fifteen (15) days from the date the participant receives the written notice of the second level Grievance decision. The participant may file a request for a DHS Fair Hearing within thirty (30) days from the mail date on the written notice of the second level Grievance decision.

External Review of Second Level Grievance Decision

The external Grievance review will be conducted by a certified review entity (CRE) not directly affiliated with PA Health & Wellness. Within two (2) Business Days from receipt of the request for an external Grievance review, DOH randomly assigns a CRE to conduct the review.  

Within sixty (60) days from the filing of the request for the external Grievance review, the CRE conducting the external Grievance review will issue a written decision to PA Health and Wellness , the participant, the participant’s representative and the provider (if the provider filed the Grievance with the participant’s consent), that includes the basis and clinical rationale for the decision.

The standard of review will be whether the service/item was Medically Necessary and appropriate under the terms of PA Health and Wellness contract. The external Grievance decision may be appealed by the participant, the participant’s representative, or the healthcare provider to a court of competent jurisdiction within sixty (60) days from the date the Participant receives notice of the external Grievance decision.

PA Health and Wellness will conduct expedited review of a Grievance at any point prior to the second level Grievance decision, if a participant or participant representative, provides PA Health and Wellness with a certification from his or her provider that the participant’s life, health or ability to attain, maintain, or regain maximum function would be placed in jeopardy by following the regular Grievance process.

This certification is necessary even when the participant’s request for the expedited review is made orally. The certification must include the provider’s signature.

PA Health and Wellness will issue the decision resulting from the expedited review in person or by phone to the Participant, the participant’s representative, if the participant has designated one, and the participant’s provider within either forty-eight (48) hours of receiving the Provider certification, or three (3) Business Days of receiving the participant’s request for an expedited review, whichever is shorter. In addition, the PA Health & Wellness will mail written notice of the decision to the participant, the participant’s representative, if the Participant has designated one, and the participant’s healthcare provider within two (2) days of the decision.

The participant, or the participant’s representative, may file a request for an expedited external Grievance review with PA Health and Wellness within two (2) Business Days from the date the participant receives PA Health and  Wellness expedited Grievance decision.  The participant may file a request for a DHS Fair Hearing within thirty (30) days from the mail date on the written notice of PA Health & Wellness expedited Grievance decision.

Participants do not have to exhaust the Complaint or Grievance process prior to filing a request for a DHS Fair Hearing. The participant or the participant’s representative may request a DHS Fair Hearings within thirty (30) days from the mail date on the initial written notice of decision and within thirty (30) days from the mail date on the written notice of PA Health & Wellness first or second level Complaint or Grievance notice of decision for any of the following:

• the denial, in whole or part, of payment for a requested service/item if based on lack of Medical Necessity;
• the denial of a requested service/item on the basis that the service/item is not a covered benefit;
• the denial or issuance of a limited authorization of a requested service/item, including the type or level of service/item;
• the reduction, suspension, or termination of a previously authorized service/item;
• the denial of a requested service/item but approval of an alternative service/item;
• the failure of PA Health and Wellness to provide services/items in a timely manner, as defined by the Department;
• the failure of PA Health and Wellness to decide a Complaint or Grievance within the timeframes
• the denial of payment after a service(s) has been delivered because the service/item was provided without authorization by a provider not enrolled in the Pennsylvania MA Program;
• the denial of payment after a service(s) has been delivered because the service/item provided is not a covered benefit for the Participant.

The request for a DHS Fair Hearing must include a copy of the written notice of decision that is the subject of the request. Requests must be sent to:

Department of Human Services

OLTL/Forum Place 6th FL

CHC Complaint, Grievance and Fair Hearings

P.O. Box 8025

Harrisburg, PA 17105-8025

Fax: 717-346-7142

WellKids by PA Health and Wellness permits an Enrollee, the Enrollee’s representative or the Enrollee’s Provider (with written permission of the Enrollee) to file a written or oral Complaint. The Enrollee, the Enrollee’s representative or the Enrollee’s Provider may review information related to the Complaint upon request and submit additional material to be considered by WellKids by PA Health and Wellness.

The Enrollee and/or the Enrollee’s representative may attend the first level Complaint review in person, via telephone or videoconference. The Enrollee may elect not to attend the first level Complaint review meeting, but the meeting will be conducted with the same protocols as if the Enrollee was present.

The first level Complaint review is performed by a first level Complaint review committee, which includes one or more employees of WellKids by PA Health and Wellness. Any individuals who make a decision on Complaints will not be involved in any previous level of review or decision making regarding the subject of the Complaint. In any case, where the reason for the complaint involves clinical issues or relates to denial of expedited resolution of a grievance, WellKids by PA Health and Wellness ensures that the decision makers are health care professionals with the appropriate clinical expertise in treating the Enrollee’s condition or disease.

The Enrollee will receive written notice of the first level Complaint committee’s decision within thirty (30) days from the date of receipt of the Complaint unless the time frame for deciding the Complaint has been extended by up to fourteen (14) days at the request of the Enrollee. The notification will include the Compliant resolution as well as instructions on how to file a second level Complaint review or external review, whichever is applicable.

If the Complaint disputes one of the following, the Enrollee may file a request for an external review :

• a denial because that the service or item is not a Covered Service;
• the failure of WellKids by PA Health and Wellness to provide a service or item in a timely manner, as defined by the Department;
• the failure of WellKids by PA Health and Wellness to decide the Complaint or Grievance within the specified time frames;
• a denial of payment by WellKids by PA Health and Wellness after the service or item has been delivered because the service or item was provided without authorization by a provider not enrolled in the MA Program;
• a denial of payment by WellKids by PA Health and Wellness after the service or item has been delivered because the service or item provided is not a Covered Service for the Enrollee; or
• a denial of an Enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities.

The Enrollee, Enrollee’s representative, or the Enrollee’s Provider (with written permission of the Enrollee) may file a request for an external review in writing or orally with WellKids by PA Health and Wellness within fifteen (15) days from the date the Enrollee receives written notice of the first level Complaint decision.

For all other Complaints, the Enrollee, Enrollee’s representative, or the Enrollee’s Provider (with written permission of the Enrollee) may file a second level Complaint either in writing or orally within forty-five (45) days from the date the Enrollee receives written notice of the first level Complaint decision.

Upon receipt of the request for a second level Complaint review, WellKids by PA Health and Wellness sends the Enrollee, and when applicable, the Enrollee’s representative an acknowledgement letter confirming the second level Complaint within three (3) business days of receipt of the request. The Enrollee and/or Enrollee’s representative may attend the second level review in person, via telephone or video conference. WellKids by PA Health & Wellness notifies the Enrollee and/or Enrollee’s representative at least fifteen (15) days prior to the date of the second level Complaint review meeting.

The second level Complaint review is performed by a second level review committee made up of three (3) or more individuals who did not participate in the matter under review. At least one third of the second level review committee will be a representative of the community and not an employee of WellKids by PA Health and Wellness or any affiliate.

The second level review committee issues a formal decision within forty-five (45) days of the receipt of the request for a second level Complaint review. WellKids by PA Health and Wellness sends a written notice of the decision to the Enrollee and/or Enrollee’s representative.

If the Enrollee is dissatisfied with the second level review committee decision, the Enrollee, Enrollee’s representative, or Enrollee’s Provider may file in writing or orally with WellKids by PA Health and Wellness for an external review of the second level Complaint decision by PID’s BMC within fifteen (15) days from the date the Enrollee receives the written notice of the second level Complaint decision.

WellKids by PA Health and Wellness must give the Enrollee at least fifteen (15) days advance written notice of the Grievance review date. The Enrollee, Enrollee’s representative, or Enrollee’s Provider who filed the grievance may attend the Grievance review in person, via telephone or video conference.

The Enrollee may elect not to attend the Grievance review meeting, but the meeting must be conducted with the same protocols as if the Enrollee was present. All Grievance review meetings must be recorded and transcribed verbatim, and the recording and transcription must be maintained as part of the Grievance record.

The Grievance review must be conducted by a Grievance review committee made up of three (3) or more individuals who were not involved in and are not the subordinates of an individual involved in any previous level of review or decision-making on the issue that is the subject of the Grievance. The Grievance review committee must include a licensed physician in the same or similar specialty that typically manages or consults on the service or item in question. If Grievance is related to dental services, the Grievance review committee must include a dentist. Other appropriate providers may participate in the review, but the licensed physician must decide the Grievance.

An Enrollee has the right to request an Expedited Grievance review at any stage of the Grievance review process. Expedited Grievances may be requested with a certification from the Enrollee’s Provider that the Enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function would be placed in jeopardy by following the regular Grievance process. The certification must include the Provider’s signature. No punitive action is taken against a Provider that requests an expedited resolution or supports an Enrollee’s Grievance. In instances where the Enrollee’s request for an Expedited Grievance is denied, the Grievance is transferred to the timeframe for standard resolution of Grievances.

Decisions for Expedited Grievances are issued within either forty-eight (48) hours of receiving the Provider certification or seventy-two (72) hours of receiving the Enrollee’s request for an expedited review, whichever is shorter, unless the time frame for deciding the expedited Grievance has been extended by up to fourteen (14) days at the request of the Enrollee.

A decision letter will be sent to the Enrollee, Enrollee’s representative, or Enrollee’s Provider that will include: the reason(s) for the decision, the policies or procedures which provide the basis for the decision, and a clear explanation of any further rights available to the Enrollee.

The Enrollee may file a request for an Expedited External Review within two (2) business days from the date the Enrollee receives WellKids by PA Health and Wellness’ expedited Grievance decision.