If a provider or managed care organization (MCO) does something that you are unhappy about or do not agree with, you have options.
You have the ability tell the MCO or the Department of Human Services (DHS) what you are unhappy about or that you disagree with what the provider or MCO has done. The documents below provide you with the information and templates needed to file necessary complaints or grievances.
Complaints and Grievances Templates
- GG(1): Notice for Failure of PH-MCO to Meet Complaint or Grievance Time Frames
- GG(2): Notice for Payment Denial Because the Service(s) Item(s) was Provided Without Authorization by a Provider not Enrolled in the Pa. Medical Assistance Program
- GG(3): Notice for Payment Denial Because the Service(s) Items(s) was not a Covered Benefit for the Member
- GG(4): Notice for Denial of Payment after a Service(s) has been Delivered Because the Emergency Room Service(s) was not Medically Necessary
- GG(5): Notice for Denial of Request to Dispute Financial Liability
- GG(6): First Level Complaint Acknowledgment Letter
- GG(7): Failure to Provide Service(s) Item(s) in a Timely Manner Acknowledgment Letter
- GG(8): First Level Complaint Decision Notice
- GG(9): Complaint Decision Notice
- GG(10): Second Level Complaint Acknowledgment Letter
- GG(11): Second Level Complaint Decision Notice
- GG(12): Expedited Complaint Decision Notice
- GG(13): Grievance Acknowledgment Letter
- GG(14): Grievance Decision Notice
- GG(15): Expedited Grievance Decision Notice
- GG(16): Notice of Failure to Receive Provider Certification for an Expedited Complaint/Grievance
- GG(17): External Grievance Review Acknowledgment Letter
- GG(18): Scheduling Review Template
- GG(19): In-Person Scheduling Review Template
- GG(20): Consent for Provider to File a Grievance for Member
- GG(21): Consent for Provider to File a Fair Hearing on Behalf of the Member