Grievances & Appeals

You may call Member Services if you need help or have questions about how to file a grievance or appeal. You cannot be punished for filing a grievance or appeal. You can have someone file an appeal for you or represent you. If you want to have someone file a grievance or appeal or represent you, we will need to have your OK in writing.  You or your representative may contact an appeal coordinator at any time for help or any questions about the grievance or appeal process.

 

You may also ask for help with a grievance or appeal by asking for a Member Advocate.  You can ask for a Member Advocate by calling Member Services.  A Member Advocate can help you:

  • File your grievance or appeal
  • Help you through the grievance or appeal process
  • Answer your questions about the grievance or appeal process
  • Help you get additional information from your doctor to help with your grievance or appeal

 

Grievances

A grievance is a statement of unhappiness, like a complaint, and can either be filed in writing or verbally over the phone.  A grievance can be about any service that you received from a doctor or by us.  A grievance does not include a denial of benefits for health care service.  Those matters are handled as appeals (see “Appeals” below).

 

Some examples of a grievance are:

  • If a provider or our employee was rude to you
  • If you feel a provider or we did not respect your rights as a member of our plan
  • If you have a problem with the quality of care or services you have received
  • If you have trouble finding or getting services from a provider

 

What should I do if I have a grievance?  To file a grievance, you can call Member Services who will help you file your grievance. Your authorized representative or doctor can also file a grievance for you if you give your OK in writing to do so.

 

You or your representative can also file a grievance in writing or by filling out a Member Grievance FormYou can find this form on our website www.highmarkhealthoptions.com.  When you file your grievance, here are the things you should include:

  • Your name and member I.D. number (found on your Health Options I.D. card)
  • Your phone number
  • Your address
  • Who is involved in the grievance?
  • What happened?
  • When did it happen?
  • Where did it happen?
  • Why you are not happy with the health care you received?

 

You can send or attach any documents to the Member Grievance Form that will help us look into the problem.  You can contact us at:

Appeals & Grievance
PO Box 22278
Pittsburgh, PA  15222

Phone: 844-325-6251

When should I file a grievance?  You, or your representative, must file your grievance within ninety (90) days of the date the problem happened.

What happens after I file a grievance?  After you file a grievance, you will get a letter from us within five (5) working days.  This letter will tell you that we have received your grievance.  It will include information about the grievance process and your rights including:

  • Your right to appoint a representative to act on your behalf
  • Your right to submit additional information
  • Your right to review or request a copy of all documentation regarding the grievance upon request free of charge.

Your grievance will be reviewed by one of our staff members who has not been involved with your grievance but knows the most about your issue.  A decision will be made within thirty (30) days after we receive your grievance.

You or your representative may extend the timeframe for decision of the grievance up to fourteen (14) days.  We may also extend the timeframe for decision of the grievance up to fourteen (14) days if additional information is necessary and the delay is in your interest.  If we extend the timeframe, we will send you a written notice of the reason for the delay.

After a decision is made, a decision letter will be mailed to you.  This letter will tell you the reason(s) for the decision.

 

What if I need help during my grievance?  If you need help filing a grievance, understanding the grievance process, or need help getting information for us to review, please contact Member Services at 1-844-325-6251 and ask for a Member Advocate.

Appeals

An appeal is a request for a review of our action.  An action is a decision to deny or limit a requested service, including the type or level of service, the reduction, suspension or termination of a service, the denial, in whole or in part or payment for a service; or the failure to provide a service in a timely manner.

 

What should I do if I have an appeal?  To file an appeal, you can call Member Services and they will help you file your appeal.  You may also have a representative or doctor file an appeal for you if you give your OK in writing to do so.  Please note that if your representative or doctor files an appeal for you, you cannot file a separate appeal on your own.

If you file your appeal by phone, you must also put your appeal request in writing within ten (10) days of calling Member Services.  An appeal review will not take place without your written signature.

You, your representative, or doctor can also file an appeal by mail.  You can also fill out a Member Appeal Form

When you file your appeal, here are the things you should include:

  • Your name and member I.D. name (found on your Health Options I.D. card)
  • Your phone number
  • Your address
  • What are you appealing?
  • Why are you appealing?
  • What do you want as a result of your appeal?

 

You may send or attach any documents that will help us with the review of your appeal.  You can contact us at:

Appeals & Grievance
PO Box 22278
Pittsburgh, PA  15222

Phone: 844-325-6251

When should I file an appeal?  You or your representative must file your appeal within ninety (90) days from the date of the “Notice of Action” letter.

What can I do to continue getting services during the appeal process?  If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting these services if:

  • You ask to continue receiving services
  • You file an appeal within ten (10) days of the date on the “Notice of Action” letter
  • You file an appeal on or before the effective date of the proposed action
  • The services were ordered by an doctor
  • The original time period covered by the original authorization has not run out

 

If we continue your services during the appeal process, we will cover these services until:

  • An appeal decision is made
  • You or your representative withdraws the appeal
  • The time period or service limits you were previously authorized for have been met
  • You receive a decision from the State Fair Hearing officer that was not in your favor

 

It is important to know that you may have to pay for the services you received while your appeal was pending if the final decision is not in your favor.

                  

What happens after I file an appeal?  You will get a letter from us within five (5) working days after your appeal.  This letter will tell you that we have received your appeal.  It will also include information about the appeal review process.  You may choose to have someone to act on your behalf.  You or your representative may submit additional information and may ask to look over all documents for the appeal.  You may also request a copy of the information used to review your appeal free of charge.  In addition, you or your representative have the right to present additional information in-person, telephonically or in writing by sending it to the address or fax number above.

 

An Appeal Committee will review your appeal and make a decision.  The Appeal Committee members include a representative of the State, a Physician and our Director of Quality or his/her designee.  The committee members have not been involved with the issue of your appeal.  If your doctor would like to discuss your appeal with one of our doctors, they may call us at 1-844-325-6254 to speak with a medical director.

 

You or your representative may extend the timeframe for making the appeal decision for up to fourteen (14) days.  We may also extend the timeframe for decision up to fourteen (14) days if additional information is necessary and the delay is in your best interest.  If we extend the timeframe, we will send you a written notice with the reason for the delay.

 

A decision letter will be mailed to you within thirty (30) days from the date you filed your appeal or within five (5) days of the decision, whichever is sooner.  This letter will tell you the reason for our decision and further appeal rights including your right to ask for a State Fair Hearing (see “What should I do to get a State Fair Hearing” below).

 

What if I need help during my appeal?  If you need help filing an appeal, understanding the appeal process, or help getting information for us to review, please contact Member services at 1-844-325-6251 and ask for a Member Advocate.  If you need a translator, we will arrange one for you at no cost.  Call Member Service for a translator.

 

What if I don’t like Health Options decision about my appeal?  If you do not agree with our decision, you or your representative, may ask for a State Fair Hearing (see “What should I do to get a State Fair Hearing” below).

 

Expedited (Fast) Appeals

 

What should I do if I need a decision faster than 30 days?  If you think the normal timeframe to review your appeal could cause you serious health concerns, you or your representative may ask for an expedited (“fast”) appeal.

You, your representative, or doctor can request a fast appeal orally or in writing.  If we agree that you should get an appeal decision faster, you will receive a decision within three (3) working days from the day you file your request.  If we do not agree, we will notify you by phone and by letter within two (2) calendar days of receiving your request that your appeal will follow the standard appeal process.

What happens after I file a fast appeal?  You may choose someone to act on your behalf.  You, your representative, or doctor may submit additional information.  Also, you or your representative may look over all documents regarding the appeal upon request free of charge.

An Appeal Committee will review your appeal and make a decision.  The Appeal Committee members include a representative of the State, a Physician and our Director of Quality or his/her designee.  The committee members have not been involved with the issue of your appeal.  If your doctor would like to discuss your appeal with one of our doctors, they may call us at 844-325-6254 to speak with a medical director.

You or your representative may extend the timeframe for decision of the appeal up to fourteen (14) days.  We may also extend the timeframe for decision of the appeal up to fourteen (14) days if additional information is necessary and the delay is in your best interest.  If we extend the timeframe, we will send you a written notice of the reason for the delay.

A decision letter will be mailed to you within three (3) working days from the date you filed your fast appeal.  This letter will tell you the reason for the decision and further appeal rights including your right to ask for a State Fair Hearing (see “What should I do to get a State Fair Hearing” below).

State Fair Hearing

A State Fair Hearing is an appeal process provided by the State of Delaware.  You may request a State Fair Hearing instead of or in addition to filing an appeal with us.

What should I do to get a State Fair Hearing?  You, or your representative, may ask for a State Fair Hearing if:

  • We have denied, suspended, terminated, or reduced a service
  • We have delayed service
  • We have failed to give you timely service

You can ask for a State Fair Hearing by calling or writing to the State’s Division of Medicaid and Medical Assistance (DMMA) office at:

Division of Medicaid & Medical Assistance

DMMA Fair Hearing Officer

1901 North DuPont Highway

PO Box 906, Lewis Building

New Castle, DE 19720

302-255-9500 or toll free at 1-800-372-2022

When should I file a State Fair Hearing?  If you or your representative are not happy with the a denial in the “Notice of Action” or an appeal decision, you may request a State Fair Hearing within ninety (90) days of the date on the “Notice of Action” or appeal decision letter.

What happens after I file a State Fair Hearing?  You or your representative will receive a letter from the State Fair Hearing officer that will tell you the date, time, and location of the hearing.  The hearing can be held in-person or by telephone.  The letter will also tell you what you need to know to get ready for the hearing.  You or your representative may review all documentation regarding the State Fair Hearing.  Health Options will also have a representative at a State Fair Hearing.

The DMMA State Fair Hearing officer will send you a letter with their decision within thirty (30) days from the date of the hearing.

How do I continue getting services during the State Fair Hearing process?  If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting services if:

  • You ask to continue receiving services
  • You file a State Fair Hearing within ten (10) days of the date on the “Notice of Action” or appeal decision letter
  • You file for a State Fair Hearing on or before the effective date of the proposed action
  • The services were ordered by an doctor
  • The original time period covered by the original authorization has not run out

If we continue your services during the State Fair Hearing process, we will continue to cover these services until:

  • You receive the State Fair Hearing decision
  • You or your representative withdraw the State Fair Hearing
  • The time period or service limits you were previously authorized for has been met

It is important to know that you may have to pay for the services you received while your State Fair Hearing was pending if the final decision is not in your favor.  If the decision was in your favor, Health Options will arrange for these services right away.

What if I do not like the State Fair Hearing decision?  If you, or someone you choose, are unhappy with the State Fair Hearing decision, you or your representative can ask for a judicial review in Superior Court.  To do this, you must file with the clerk (Prothonotary) of the Superior Court within thirty (30) days of the date of the State Fair Hearing decision.

Provider Appeals

There are two types of Provider Appeals. 

Provider Disputes are requests that are not regarding medical necessity rather are administrative in nature such as, but not limited to, disputes regarding the amount paid, appeals of denials regarding lack of modifiers, refunded claim payments due to incorrect payment or coordination of benefit issues.

Clinical Provider Appeals  are cases that are denied due to lack of prior authorization or denied based on medical necessity.

To submit a Provider Dispute, please use this contact information below.

  1. Send us a request by fax to:

    • All Providers: 1-844-207-0334

  2. Mail in a request to:

    • Non-Participating Medicare Provider, and any Pre-Service Appeals:

      Health Options
      Attn: Claims Review
      444 Liberty Avenue, Suite 2100
      Pittsburgh, PA 15222

      To submit a Clinical Provider Appeal, please use this contact information below.

  3. Send us a request by fax to:

    • All Member Appeals or Grievances Appeals: 412-255-4503

    • All Medicaid Providers: 855-501-3904

  4. Mail in a request to:

  5. All Medicaid Providers:

    Health Options
    Attn: Clinical Provider Appeals
    P.O. Box 22278
    Pittsburgh, PA 15222

    *NOTE: If you are a non-participating provider submitting a Medicare Claim/Post Service appeal, you must submit a Waiver of Liability in accordance with Medicare Law in order for your appeal to be considered. We have attached one for your convenience for submission with your appeal.

    Wavier Of Liability Form