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.
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.
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.
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.
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.
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.
