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Complaints and grievances

• Can a provider file a grievance?
• Can a provider file a complaint against another provider?
• Can the member continue services during a grievance, and will the provider claims be paid for these services?
• Can a provider submit additional information to PerformCare during the grievance process?
• What happens if the grievance process continues to the next authorization period?
• Who facilitates Level II grievances in the Capital Area?

Can a provider file a grievance?

Yes. As long as there is member consent. A provider must have the authorization for representation form signed by the member and sent to PerformCare before PerformCare can open and process the grievance.

Can a provider file a complaint against another provider?

Yes. However, PerformCare encourages resolution of provider issues before contacting PerformCare. If a provider feels they have exhausted all options of working with another provider, they can call PerformCare to file a provider to provider complaint.

Can the member continue services during a grievance, and will the provider claims be paid for these services?

Yes, as long as the services that were requested are a continuation of the previously authorized service. PerformCare uses a service notification form that is generated and faxed to the provider to verify what services can be continued and for a specific timeframe. This notification is also sent to internal departments to generate an authorization for continuation rights for that specific period of time for claim payment.

Can a provider submit additional information to PerformCare during the grievance process?

Yes. It is within the Member's rights of the grievance process and any party on behalf of the Member to submit additional documentation as part of the grievance review. However, if a provider is submitting an addendum regarding the current services that are being reviewed in the grievance, this will be used as additional documentation only for the grievance. A separate Medical Necessary Criteria (MNC) review will not occur for that packet. If new services are being requested, then this is a separate MNC review.

What happens if the grievance process continues to the next authorization period?

If the grievance process is still pending when a new re-authorization request is to be submitted, the provider will submit the new authorization per PerformCare's normal process and regulations for submitting reauthorization requests for the particular level of care.

Who facilitates Level II grievances in the Capital Area?

CABHC will begin facilitating Level II grievances for the Capital Area only (Cumberland, Dauphin, Lancaster, Lebanon, and Perry Counties) in June of 2007. This will not change the filing or meeting scheduling process, you will still contact PerformCare. The only change is the CABHC staff will be facilitating the actual Level II meeting.

Other complaints and grievances resources

• QI-CG-001: Complaints and grievances policy
• Authorization for representation - Member complaints or grievances
• Appendix T – HealthChoices behavioral health services guidelines for mental health medical necessity criteria
• Expedited certification form (PDF)