You have the right to make a complaint if you have concerns or problems related to your coverage or care. Appeals are the type of complaint you make when you want us to reconsider and change an initial coverage decision. A grievance, on the other hand, is the type of complaint you make if you have any other type of problem with your plan or with a plan provider. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your plan pharmacist or others behave, or the cleanliness of a plan pharmacy.

If you have a grievance, we encourage you to first call Client Services. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.

We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

If we deny your request to expedite an initial decision or redetermination, you may file a fast grievance. We have 24 hours to notify you of our decision regarding your fast grievance.

In order for us to discuss or investigate concerns regarding your medical care or coverage with someone other than yourself, you must provide us with authorization. To find out how to authorize the release of your personal and health information, click here.