Appeals, complaints, and Grievances: Helping your patients
What is a complaint?
A complaint, which can be lodged by a consumer or a provider, is an expression of
dispute regarding the operations, coverage, or management policies of a health plan.
Consumers can register complaints about providers, or about plan operations. Examples of
complaints include problems with a particular pharmacy, problems with telephone access,
etc. Because these do not involve medical necessity, physicians are not involved in
advocating for patients who have complaints. However, providers can file complaints,
either with the plan or with DPW. A provider with a complaint about plan operations can
call the
What is a grievance?
A grievance is a request by either the patient, or by the provider on behalf of the
patient, to reconsider a decision concerning medical necessity or appropriateness of
health services. If a service is approved only in part, that is considered a denial by the
plan and may be appealed. If a patient is receiving a service – whether it is a
medication, an inpatient stay, or skilled nursing at home or in a facility – and that
service is then denied in whole or in part, if the denial is appealed within ten days the
plan must continue to provide for the service until the dispute is resolved.
What recourse do patients and providers have?
Patients can either file a grievance with the plan, or request a fair hearing directly
from the department of public welfare. Filing a grievance with the plan does not preclude
later asking for a fair hearing. If the initial appeal is denied, there are second level
grievance procedures and possibilities for external review.
What if a denied service is urgent for the patient?
It is possible to file an expedited grievance which must be resolved in 48 hours.
What is my role as a physician in this procedure?
If you have prescribed something for your patient which you believe is indicated, your
job is to advocate for the patient to obtain the medication, nursing service, hospital
days, etc. The best way to do this is to write an excellent letter of medical necessity.
What if I don’t feel able to advise patients in this process?
Grievances are part of the legal contract. This is a good time to have the patient call
the Pennsylvania Health Law Project, 1-800-274-3258. The lawyers will be able to advise
the patient and possibly provide representation if it is appropriate.
