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:
- Deny, in whole or in part, payment for a service/item
- Deny or issue a limited authorization of a requested service/item, including a determination based on the type or level of service/item;
- Reduce, suspend, or terminate a previously authorized service/item
- Deny the requested service/item but approve an alternative service/item
- Deny a request for a Benefit Limit Exception (BLE).
* This term does not include a Complaint.
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 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 & 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 & 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 & 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 & 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 & Wellness second level Complaint decision.
PA Health & 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 & 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 & Wellness will inform the participant that the provider must submit a certification as to the reasons why the expedited review is needed.
PA Health & 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 & 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 & 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 & 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 & 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 & 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 & 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 & 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 & 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 & 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 & Wellness within two (2) Business Days from the date the participant receives PA Health & 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 & Wellness to provide services/items in a timely manner, as defined by the Department;
- the failure of PA Health & 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
OMAP – HealthChoices Program
Complaint, Grievance and Fair Hearings
P.O. Box 2675
Harrisburg, Pennsylvania 17105-2675