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Complaints and grievances

If you are unhappy with PerformCare or your provider or you do not agree with a decision PerformCare made about delivery of your care, you can do something about it by filing a complaint or grievance.

If PerformCare decides that a service you or your provider asked for is not medically necessary you can file a grievance.

You can call or write PerformCare to find out what you can do. Staff is available to tell you what your rights are and what actions you can take if you are unhappy with your care or your Provider or if you are dissatisfied with a decision PerformCare made.

If you would like to know more, keep reading for a more detailed explanation about complaints, grievances and fair hearings. If you need any of this explained in more detail, or if you have any questions about any of this information, call PerformCare Member Services for your area and let us know how we can help you.

Download our complaints and grievances pamphlet (PDF) that explains our process to handle your complaints and grievances.




What is a complaint and how do I file a complaint?

You can file a complaint when you are unhappy with PerformCare, or if you or your provider do not agree with a decision made by PerformCare.

Examples of a complaint:

  • You are unhappy with the care you are getting.
  • You are unhappy that you cannot get the service you want because it is not a covered service.
  • You are unhappy that you have not received services that were approved.

PerformCare providers must provide services within one hour for emergencies, within 24 hours for urgent situations, and within 7 days for routine appointments and specialty referrals. If a treatment plan is approved, services must be provided according to the prescribed treatment plan.



What should I do if I have a complaint?

File a first level complaint:

Call PerformCare's Member Services (toll-free) for your county and tell us your complaint:

  • 1-888-722-8646 Cumberland, Dauphin, Lancaster, Lebanon, and Perry Counties
  • 1-866-773-7891 Bedford and Somerset Counties
  • 1-866-773-7917 Franklin and Fulton Counties

This is called a first level complaint.

When should I file a first level complaint?

You must file a complaint within 45 days of getting a letter telling you that:

  • PerformCare has decided you cannot get a service you want because it is not a covered service.
  • PerformCare will not pay a Provider for a service you received because the service was provided - without authorization from a Provider not enrolled in MA.
  • PerformCare will not pay a Provider for a service you received because it is not a covered benefit.
  • PerformCare did not decide a first level complaint or grievance you filed earlier within 30 days of when you filed it.
  • You must file a complaint within 45 days of the date you should have received a service if your Provider did not give you the service.

You may file all other complaints at any time.

What happens after I file a first level complaint?

PerformCare will send you a letter to let you know we received your complaint. The letter will tell you about the first level complaint process.

You may ask PerformCare to see any information we have about your complaint. You may also send information that may help with your complaint to PerformCare.

If you filed a complaint because of one of the reasons listed below, you can be included in the first level complaint review. You must call PerformCare within 10 days of the date on the letter to tell us that you want to be included.

  • You are unhappy that you have not received services that you have been approved to get.
  • You are unhappy that PerformCare has decided you cannot get a service you want because it is not a covered service.
  • You are unhappy that PerformCare will not pay a provider for a service you received because the service was provided without authorization from a provider not enrolled in MA.
  • You are unhappy that PerformCare will not pay a provider for a service you received because it is not a covered benefit.
  • You are unhappy that PerformCare did not decide a first level complaint or grievance within 30 days.

You can come to our offices or be included by phone. You do not have to attend if you do not want to. If you do not attend, it will not affect our decision.

One or more PerformCare staff who has not been involved in the issue you filed your complaint about will make a decision on your complaint. Your complaint will be decided no more than 30 days after we received it.

A letter will be mailed to you no more than 5 business days after PerformCare makes its decision. This letter will tell you the reason for the decision. It will also tell you how to file a second level complaint if you don’t like the decision.



How do I continue to get services during my complaint?

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a complaint that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.



What if I don't like PerformCare's decision?

Second level complaint

If you are not happy with PerformCare's first level complaint decision, you may file a second level complaint with PerformCare.

When should I file a second level complaint?

You must file your second level complaint within 45 days of the date you get the first level complaint decision letter. Use the same address or phone number you used to file your first level complaint.

What happens after I file a second level complaint?

PerformCare will send you a letter to let you know we received your complaint. The letter will tell you about the second level complaint process.

You may ask PerformCare to see any information we have about your complaint. You may also send information that may help with your complaint to PerformCare.

You can come to a meeting of the second level complaint committee or be included by phone. PerformCare will contact you to ask if you want to come to the meeting. You don’t have to attend if you do not want to. If you do not attend, it will not affect our decision.

The second level complaint review committee will have three or more people on it. At least one PerformCare member will be on the committee. The members of the committee will not have been involved in the issue you filed your complaint about. The committee will make a decision no more than 30 days from the date PerformCare received your second level complaint.

A letter will be mailed to you within 5 business days after the committee makes its decision. This letter will tell you the reason for the decision. It will also tell you how to ask for an external complaint review if you don’t like the decision.

What to do to continue getting services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a second level complaint that is hand-delivered or postmarked within 10 days of the date on the first level complaint decision letter, the services will continue until a decision is made.



What if I still don't like PerformCare's decision?

External complaint review

If you are not happy with PerformCare’s second level complaint decision, you may ask for a review of your complaint by the Department of Health or the Insurance Department. The Department of Health handles complaints that involve the way a Provider gives care or services. The Insurance Department reviews complaints that involve PerformCare’s policies and procedures.

You must ask for an external review within 15 days of the date you receive the second level complaint decision letter. If you ask, the Department of Health will help you put your complaint in writing.

You must send your request for external review in writing to either:

Pennsylvania Department of Health Bureau of Managed Care Attention:

Complaint Appeals
P.O. Box 90
Harrisburg, PA 17108-0080
1-888-466-2787

 or

Pennsylvania Insurance Department Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, PA 17120
1-877-881-6388

If you send your request for external review to the wrong department, it will be sent to the correct department. The Department of Health or the Insurance Department will get your file from PerformCare. You may also send them any other information that may help with the external review of your complaint. You may be represented by an attorney or another person during the external review.

A decision letter will be sent to you after the decision is made. This letter will tell you the reason for the decision and what you can do if you don’t like the decision.

What to do to continue getting services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a request for an external complaint review that is hand-delivered or postmarked within 10 days of the date on the second level complaint decision letter, the services will continue until a decision is made.



What is a grievance and how do I file for a grievance?

You file a grievance when you disagree with PerformCare’s decision that a service requested by you or your provider is not medically necessary.

You can file a grievance if PerformCare does any one of these things:

  • Denies a service for medical necessity reasons
  • Approves less than what was asked for
  • Approves a different service from the one that was asked for


What should I do if I have a grievance?

First level grievance

If PerformCare does not completely approve a service for you, we will tell you in a letter. The letter will tell you how to file a grievance. You have 45 days from the date you receive this letter to file a grievance.

To file a grievance, you can:

Call PerformCare Member Services (toll-free) for your county and tell us your grievance:

  • 1-888-722-8646 Cumberland, Dauphin, Lancaster, Lebanon, and Perry Counties
  • 1-866-773-7891 Bedford and Somerset Counties
  • 1-866-773-7917 Franklin and Fulton Counties

Or write down your complaint and send it to us at:

PerformCare
8040 Carlson Road
Harrisburg, PA 17112

Your provider can file a grievance for you if you give the provider your consent in writing to do so.

NOTE: If your provider files a grievance for you, you cannot file a separate grievance on your own.

What happens after I file a first level grievance?

PerformCare will send you a letter to let you know we received your grievance. The letter will tell you about the first level grievance process. You may ask PerformCare to see any information we have about your grievance. You may also send information that may help with your grievance to PerformCare.

If you want to be included in the first level grievance review, you must call us within 10 days of the date on the letter we sent you to let you know we received your grievance. You can come to our offices or be included by phone. You don’t have to attend if you do not want to. If you do not attend, it will not affect our decision.

A committee of one or more PerformCare staff, including a doctor or licensed psychologist who has not been involved in the issue you filed your grievance about, will make a decision about your first level grievance. Your grievance will be decided no more than 30 days after we received it.

A letter will be mailed to you no more than 5 business days after PerformCare makes its decision. This letter will tell you the reason for the decision. It will also tell you how to file a second level grievance if you don’t like the decision.

What to do to continue getting services:

If you have been receiving services that are being reduced, changed, or stopped, and you file a grievance that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services you have been receiving are being reduced, changed, or stopped, the services will continue until a decision is made.



What if I don't like the decision?

Second level grievance

If you are not happy with PerformCare’s first level grievance decision, you may file a second level grievance with PerformCare.

When should I file a second level grievance?

You must file your second level grievance within 45 days of the date you get the first level grievance decision letter. Use the same address or phone number you used to file your first level grievance.

What happens after I file a second level grievance?

PerformCare will send you a letter to let you know we received your grievance. The letter will tell you about the second level grievance process. You may ask PerformCare to see any information we have about your grievance. You may also send information that may help with your grievance to PerformCare.

You can come to a meeting of the second level grievance committee or be included by phone. PerformCare will contact you to ask if you want to come to the meeting. You don’t have to attend if you do not want to. If you do not attend, it will not affect our decision.

The second level grievance review committee will have three or more people on it. At least one PerformCare member and a doctor or licensed psychologist will be on the committee. The members of the committee will not have been involved in the issue you filed your grievance about. The committee will make a decision no more than 30 days from the date PerformCare received your second level grievance.

A letter will be mailed to you within 5 business days after the committee makes its decision. This letter will tell you the reason for the decision. It will also tell you how to ask for an external grievance review if you don’t like the decision.

How do I continue to get services during my grievance?

What to do to continue getting services:

If you have been receiving services that are being reduced, changed, or stopped, and you file a second level grievance that is hand-delivered or postmarked within 10 days of the date on the first level grievance decision letter, the services will continue until a decision is made.



What if I still don't like the decision?

External grievance review

If you are not happy with PerformCare’s second level grievance decision, you can ask for an external grievance review. You must call or send a letter to PerformCare asking for an external grievance review within 15 days of the date you received the second level grievance decision letter. Use the same address and phone number you used to file your first level grievance. We will then send your request to the Department of Health. The Department of Health will notify you of the external grievance reviewer’s name, address and phone number. You will also be given information about the external review process.

PerformCare will send your grievance file to the reviewer. You may provide additional information that may help with the external review of your grievance, to the reviewer, within 15 days of filing the request for an external grievance review.

Request a fair hearing

You may ask for a fair hearing from the Department of Public Welfare. Your request for a fair hearing must be in writing and must be postmarked within 30 days from the date on this notice. Your request should include the following information:

  • Your (the member’s) name, social security number, and date of birth
  • A telephone number where you can be reached during the day
  • Whether you want to have a hearing in person or by telephone
  • The reason(s) you are asking for a fair hearing, or a copy of this notice
  • A copy of the original denial notice, if available

Your request for a fair hearing must be sent to the following address:

Department of Public Welfare
Office of Mental Health and Substance Abuse Services
Division of Grievances and Appeals
Beechmont Building #32
P.O. Box 2675
Harrisburg, PA 17105-2675

The Department will issue a decision within 90 days from when it receives your request (see your member handbook for more details).

To ask for an early decision

If your doctor or psychologist believes that waiting 30 days to get a decision could harm your health, you may ask that your grievance be decided more quickly. To do this:

  • Call PerformCare at Capital Area 1-888-722-8646; Bedford/Somerset 1-866-773-7891 or Franklin/Fulton 1-866-773-7917.
  • Your doctor or psychologist must fax a letter to 717-671-6555 explaining why taking 30 days to decide your grievance could harm your health.

PerformCare will notify you of the decision within 48 hours from when we receive your doctor’s or psychologist’s letter or within 3 business days from when we receive your request, whichever is sooner.