Complaints, Grievances, and Fair Hearings

Complaints and Grievances

If a provider or PerformCare does something you are unhappy about or do not agree with, you can tell PerformCare or the Department of Human Services what you are unhappy about or that you disagree with what the provider or PerformCare has done. This section describes what you can do and what will happen.

Download a copy of PerformCare's Complaints and Grievances brochure (PDF)
Learn how to become a member of the Complaint and Grievance Review Committee

Complaints

What is a Complaint?

A Complaint is when you tell PerformCare you are unhappy with PerformCare or your provider or you do not agree with a decision by PerformCare.

Some things you may complain about:

The care you are getting.
Not being able to get the service you want because it is not a covered service.
Not getting services that PerformCare has approved.

First-Level Complaint

What Should I Do If I Have a Complaint?

To file a First-Level Complaint, you can do either of the following:

Call PerformCare Member Services at 1-888-722-8646 for Cumberland, Dauphin, Lancaster, Lebanon, and Perry counties or at 1-866-773-7917 for Franklin and Fulton counties and tell PerformCare your Complaint.
Write down your Complaint and send it to PerformCare by mail or fax.

PerformCare's address and fax number for Complaints:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
Fax: 1-717-671-6555

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

When Should I File a First-Level Complaint?

Some Complaints have a time limit on filing. You must file a Complaint within 60 days of getting a notice telling you that:

PerformCare has decided that you cannot get a service you want because it is not a covered service.
PerformCare will not pay a provider for a service you got.
PerformCare did not tell you its decision about a Complaint or Grievance you told PerformCare about within 30 days from when PerformCare got your Complaint or Grievance.
PerformCare has denied your request to disagree with PerformCare’s decision that you have to pay your provider.

You must file a Complaint within 60 days of the date you should have gotten a service if you did not get a service. The time by which you should have received a service is listed below:

If you need services because of an emergency, services must be provided within one hour.
If you need services because of an urgent situation, services must be provided within 24 hours.
If you need a routine appointment or specialty referral, your appointment must be within seven days.

You may file all other Complaints at any time.

What Happens After I File a First-Level Complaint?

After you file your Complaint, you will get a letter from PerformCare telling you that PerformCare has received your Complaint, and describing the First-Level Complaint review process.

You may ask PerformCare to see any information PerformCare has about the issue you filed your Complaint about at no cost to you. You may also send information that you have about your Complaint to PerformCare.

You may attend the Complaint review if you want to. You may appear at the Complaint review in person or attend by phone. If you decide you do not want to attend the Complaint review, it will not affect the decision.

A committee of one or more PerformCare staff who were not involved in and do not work for someone who was involved in the issue you filed your Complaint about will meet to make a decision about your Complaint. If the Complaint is about a clinical issue, a licensed doctor will be on the committee.

PerformCare will mail you a notice within 30 days from the date you filed your First-Level Complaint to tell you the decision on your First-Level Complaint. The notice will also tell you what you can do if you do not like the decision.

What If I Do Not Like PerformCare’s Decision?

You may ask for an external Complaint review, a Fair Hearing, or an external Complaint review and a Fair Hearing if the Complaint is about one of the following:

PerformCare's decision that you cannot get a service you want because it is not a covered service.
PerformCare's decision to not pay a provider for a service you got.
PerformCare's failure to decide a Complaint or Grievance you told PerformCare about within 30 days from when PerformCare got your Complaint or Grievance.
You not getting a service within the time by which you should have received it PerformCare's decision to deny your request to disagree with PerformCare’s decision that you have to pay your provider.

You must ask for an external Complaint review within 15 days of the date you got the First-Level Complaint decision notice.

You must ask for a Fair Hearing within 120 days from the date on the notice telling you the Complaint decision.

For all other Complaints, you may file a Second-Level Complaint within 45 days of the date you got the Complaint decision notice.

Second-Level Complaint

What Should I Do If I Want to File a Second-Level Complaint?

To file a Second-Level Complaint, you can do one of the following:

Call PerformCare Member Services for the Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917 and tell PerformCare your Second-Level Complaint.
Write down your Second-Level Complaint and send it to PerformCare by mail or fax.

PerformCare's address and fax number for Second-Level Complaints:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
Fax: 1-717-671-6555

What Happens After I File a Second-Level Complaint?

After you file your Second-Level Complaint, you will get a letter from PerformCare telling you that PerformCare has received your Complaint, and describing the Second-Level Complaint review process.

You may attend the Complaint review if you want to. PerformCare will tell you the location, date, and time of the Complaint review at least 10 days before the Complaint review. You may appear at the Complaint review in person or attend by phone. If you decide that you do not want to attend the Complaint review, it will not affect the decision.

A committee of three or more people, including at least one person who does not work for PerformCare, will meet to decide on your Second-Level Complaint. The PerformCare staff on the committee will not have been involved in and will not have worked for someone who was involved in the issue you filed your Complaint about. If the Complaint is about a clinical issue, a licensed doctor will be on the committee.

PerformCare will mail you a notice within 45 days from the date you filed your Second-Level Complaint to tell you the decision on your Second-Level Complaint. The letter will also tell you what you can do if you do not like the decision.

What If I Do Not Like PerformCare’s Decision on My Second-Level Complaint?

You may ask for an external review by either the Department of Health or the Insurance Department.

You must ask for an external review within 15 days of the date you got the Second-Level Complaint decision notice.

External Complaint Review

How Do I Ask for an External Complaint Review?

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

Pennsylvania Department of Health
Bureau of Managed Care Healthand Welfare Building
Room 912
625 Forster Street
Harrisburg, PA 17120-0701
Phone Number: 1-888-466-2787

Pennsylvania Insurance Department
Bureau of Consumer Services
Room 1209
Strawberry Square
Harrisburg, PA 17120
Phone Number: 1-877-881-6388

If you ask, the Department of Health will help you put your Complaint in writing.

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. If you send your request for external review to the wrong department, it will be sent to the correct department.

What Happens After I Ask for an External Complaint Review?

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, such as your representative, during the external review.

A decision letter will be sent to you after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision.

Grievances

What Is a Grievance?

When PerformCare denies, decreases, or approves a service different than the service you requested because it is not medically necessary, you will get a notice telling you PerformCare's decision.

A Grievance is when you tell PerformCare you disagree with PerformCare's decision.

What Should I Do If I Have a Grievance?

To file a Grievance, you can do one of the following:

Call PerformCare Member Services for the Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917 and tell PerformCare your Grievance.
Write down your Grievance and send it to PerformCare by mail or fax.

PerformCare's address and fax number for Grievances:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
Fax: 1-717-671-6555

Your provider can file a Grievance for you if you give the provider your consent in writing to do so. If your provider files a Grievance for you, you cannot file a separate Grievance on your own.

When Should I File a Grievance?

You must file a Grievance within 60 days from the date you get the notice telling you about the denial, decrease, or approval of a different service for you.

What Happens After I File a Grievance?

After you file your Grievance, you will get a letter from PerformCare telling you that PerformCare has received your Grievance, and about the Grievance review process.

You may ask PerformCare to see any information that PerformCare used to make the decision you filed your Grievance about at no cost to you. You may also send information that you have about your Grievance to PerformCare.

You may attend the Grievance review if you want to. PerformCare will tell you the location, date, and time of the Grievance review at least 10 days before the day of the Grievance review. You may appear at the Grievance review in person or attend by phone. If you decide you do not want to attend the Grievance review, it will not affect the decision.

A committee of three or more people, including a licensed doctor, will meet to decide on your Grievance. The PerformCare staff on the committee will not have been involved in and will not have worked for someone who was involved in the issue you filed your Grievance about.

PerformCare will mail you a notice within 30 days from the date you filed your Grievance to tell you the decision on your Grievance. The notice will also tell you what you can do if you do not like the decision.

What If I Do Not Like PerformCare's Decision?

You may ask for an external Grievance review or a Fair Hearing, or you may ask for both. A Fair Hearing is your appeal presented at the DHS, Bureau of Hearings and Appeals, to make a decision regarding your complaint. An external Grievance review is a review by a doctor who does not work for PerformCare.

You must ask for an external Grievance review within 15 days of the date you got the Grievance decision notice.

You must ask for a Fair Hearing from the Department of Human Services within 120 days from the date on the notice telling you the Grievance decision.

External Grievance Review

How Do I Ask for External Grievance Review?

To ask for an external Grievance review, you can do one of the following:

Call PerformCare Member Services for the Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917 and tell PerformCare your Grievance.
Write down your Grievance and mail it to PerformCare at:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
or fax it to: 1-717-671-6555

PerformCare will send your request for external Grievance review to the Department of Health.

What Happens After I Ask for an External Grievance Review?

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 Grievance 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.

You will receive a decision letter within 60 days of the date you asked for an external Grievance review. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision.

Expedited Complaints and Grievances

What Can I Do If My Health Is at Immediate Risk?

If your doctor believes that waiting 30 days to get a decision about your Complaint or Grievance could harm your health, you or your doctor may ask that your Complaint or Grievance be decided more quickly. For your Complaint or Grievance to be decided more quickly:

You must ask PerformCare for an early decision by calling PerformCare Member Services for the Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917, or by faxing a letter to 1-717-671-6555.
Your doctor should fax a signed letter to PerformCare within 72 hours of your request for an early decision that explains why PerformCare taking 30 days to tell you the decision about your Complaint or Grievance could harm your health.

If PerformCare does not receive a letter from your doctor and the information provided does not show that taking the usual amount of time to decide your Complaint or Grievance could harm your health, PerformCare will decide your Complaint or Grievance in the usual time frame of 30 days from when PerformCare first got your Complaint or Grievance.

Expedited Complaint and Expedited External Complaint

Your expedited Complaint will be reviewed by a committee that includes a licensed doctor. Members of the committee will not have been involved in and will not have worked for someone who was involved in the issue you filed your Complaint about.

You may attend the expedited Complaint review if you want to. You can attend the Complaint review in person, but may have to attend by phone because PerformCare has only a short time to decide an expedited Complaint. If you decide you do not want to attend the Complaint review, it will not affect the decision.

PerformCare will tell you the decision about your Complaint within 48 hours of when PerformCare gets your doctor's letter explaining why the usual time frame for deciding your Complaint will harm your health, or within 72 hours from when PerformCare gets your request for an early decision, whichever is sooner, unless you ask PerformCare to take more time to decide your Complaint.

You can ask PerformCare to take up to 14 more days to decide your Complaint. You will also get a notice telling you the reason(s) for the decision and how to ask for expedited external Complaint review, if you do not like the decision.

If you did not like the expedited Complaint decision, you may ask for an expedited external Complaint review from the Department of Health within two business days from the date you get the expedited Complaint decision notice. To ask for expedited external review of a Complaint, you can do one of the following:

Call PerformCare Member Services for the Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917 and tell PerformCare your Complaint.
Write down your Complaint and send it to PerformCare by mail or fax:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
Fax: 1-717-671-6555

Expedited Grievance and Expedited External Grievance

A committee of three or more people, including a licensed doctor, will meet to decide your Grievance. The PerformCare staff on the committee will not have been involved in and will not have worked for someone who was involved in the issue you filed your Grievance about.

You may attend the expedited Grievance review if you want to. You can attend the Grievance review in person, but may have to attend by phone because PerformCare has only a short time to decide the expedited Grievance. If you decide you do not want to attend the Grievance review, it will not affect our decision.

PerformCare will tell you the decision about your Grievance within 48 hours of when PerformCare gets your doctor’s letter explaining why the usual time frame for deciding your Grievance will harm your health, or within 72 hours from when PerformCare gets your request for an early decision, whichever is sooner, unless you ask PerformCare to take more time to decide your Grievance. You can ask PerformCare to take up to 14 more days to decide your Grievance.

You will also get a notice telling you the reason(s) for the decision and what to do if you do not like the decision. If you do not like the expedited Grievance decision, you may ask for an expedited external Grievance review, or an expedited Fair Hearing by the Department of Human Services, or both an expedited external Grievance review and an expedited Fair Hearing.

You must ask for expedited external Grievance review by the Department of Health within two business days from the date you get the expedited Grievance decision notice. To ask for expedited external review of a Grievance, you can do one of the following:

Call PerformCare Member Services for Capital Area at 1-888-722-8646 or for Franklin and Fulton counties at 1-866-773-7917 and tell PerformCare your Grievance.
Write down your Grievance and send it to PerformCare by mail or fax:

PerformCare
Attention: Complaint and Grievance Department
8040 Carlson Road
Harrisburg, PA 17112
Fax: 1-717-671-6555

PerformCare will send your request to the Department of Health within 24 hours after receiving it. You must ask for a Fair Hearing within 120 days from the date on the notice telling you the expedited Grievance decision.

What Kind of Help Can I Have With the Complaint and Grievance Processes?

If you need help filing your Complaint or Grievance, a staff member of PerformCare will help you. This person can also represent you during the Complaint or Grievance process. You do not have to pay for the help of a staff member. This staff member will not have been involved in any decision about your Complaint or Grievance.

You may also have a family member, friend, lawyer, or other person help you file your Complaint or Grievance. This person can also help you if you decide you want to appear at the Complaint or Grievance review.

At any time during the Complaint or Grievance process, you can have someone you know represent you or act for you. If you decide to have someone represent or act for you, tell PerformCare, in writing, the name of that person and how PerformCare can reach them.

You or the person you choose to represent you may ask PerformCare to see any information PerformCare has about the issue you filed your Complaint or Grievance about at no cost to you.

You may call PerformCare's Member Services toll-free phone number for the Capital Area at 1-888-722-8646 and for Franklin and Fulton counties at 1-866-773-7917 if you need help or have questions about Complaints and Grievances. You can also contact your local legal aid office at 1-800-322-7572 or call the Pennsylvania Health Law Project at 1-800-274-3258.

Persons Whose Primary Language Is Not English

If you ask for language services, PerformCare will provide the services at no cost to you.

These services may include:

Providing in-person language interpreters.
Providing language interpreters over the phone.
Providing document translation.

Persons With Disabilities

PerformCare will provide persons with disabilities with the following help in presenting Complaints or Grievances at no cost, if needed. This help includes:

Providing sign language interpreters.
Providing information submitted by PerformCare at the Complaint or Grievance review in an alternative format. The alternative format version will be given to you before the review.
Providing someone to help copy and present information.

Department of Human Services Fair Hearings

In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something PerformCare did or did not do. These hearings are called "Fair Hearings." You can ask for a Fair Hearing after PerformCare decides your First-Level Complaint or your Grievance.

What Can I Request a Fair Hearing About and By When Do I Have to Ask for a Fair Hearing?

Your request for a Fair Hearing must be postmarked within 120 days from the date on the notice telling you PerformCare’s decision on your First-Level Complaint or Grievance about the following:

The denial of a service you want because it is not a covered service.
The denial of payment to a provider for a service you got and the provider can bill you for the service.
PerformCare’s failure to decide a First-Level Complaint or Grievance you told PerformCare about within 30 days from when PerformCare got your Complaint or Grievance.
The denial of your request to disagree with PerformCare’s decision that you have to pay your provider.
The denial of a service, decrease of a service, or approval of a service different from the service you requested because it was not medically necessary.
You’re not getting a service within the time by which you should have received a service.

You can also request a Fair Hearing within 120 days from the date on the notice telling you that PerformCare failed to decide a First-Level Complaint or Grievance you told PerformCare about 30 days from when PerformCare got your Complaint or Grievance.

How Do I Ask for a Fair Hearing?

Your request for a Fair Hearing must be in writing.

Your Fair Hearing request needs to include all of the following information:

Your (the member’s) name and date of birth.
A phone number where you can be reached during the day.
Whether you want to have the Fair Hearing in person or by phone.
The reason(s) you are asking for a Fair Hearing.
A copy of any letter you received about the issue you are asking for a Fair Hearing about.

You may mail your request for a Fair Hearing to the following address:

Department of Human Services
Office of Mental Health Substance Abuse Services
Division of Quality Management
Commonwealth Towers, 12th Floor
P.O. Box 2675
Harrisburg, PA 17105-2675

Or you may fax your request for a Fair Hearing to 1-717-772-7827.

What Happens After I Ask for a Fair Hearing?

You will get a letter from the Department of Human Services' Bureau of Hearings and Appeals telling you the date, time, and location for the hearing. You will receive this letter at least 10 days before the date of the hearing.

You may attend the Fair Hearing in person or by phone. A family member, friend, lawyer, or other person may help you during the Fair Hearing. You must participate in the Fair Hearing. PerformCare will also go to your Fair Hearing to explain why PerformCare made the decision or explain what happened.

You may ask PerformCare to give you any records, reports, and other information about the issue you requested your Fair Hearing about at no cost to you.

When Will the Fair Hearing Be Decided?

The Fair Hearing will be decided within 90 days from when you filed your Complaint or Grievance with PerformCare, not including the number of days between the date on the written notice of the PerformCare's First-Level Complaint decision or Grievance decision and the date you asked for a Fair Hearing.

If you requested a Fair Hearing because PerformCare did not tell you its decision about a Complaint or Grievance you told PerformCare about within 30 days from when PerformCare got your Complaint or Grievance, your Fair Hearing will be decided within 90 days from when you filed your Complaint or Grievance with PerformCare, not including the number of days between the date on the notice telling you that PerformCare failed to timely decide your Complaint or Grievance and the date you asked for a Fair Hearing.

The Department of Human Services will send you the decision in writing and tell you what to do if you do not like the decision.

If your Fair Hearing is not decided within 90 days from the date the Department of Human Services receives your request, you may be able to get your services until your Fair Hearing is decided. You can call the Department of Human Services at 1-800-798-2339 to ask for your services.

Expedited Fair Hearing

What Can I Do If My Health Is at Immediate Risk?

If your doctor believes that waiting the usual time frame for deciding a Fair Hearing could harm your health, you may ask that the Fair Hearing take place more quickly. This is called an expedited Fair Hearing. You can ask for an early decision by calling the department at 1-800-798-2339 or by faxing a letter to 1-717-772-6328. Your doctor must fax a signed letter to 1-717-772-6328 explaining why taking the usual amount of time to decide your Fair Hearing could harm your health.

If your doctor does not send a letter, your doctor must testify at the Fair Hearing to explain why taking the usual amount of time to decide your Fair Hearing could harm your health. The Bureau of Hearings and Appeals will schedule a phone hearing and will tell you its decision within three business days after you asked for a Fair Hearing.

If your doctor does not send a written statement and does not testify at the Fair Hearing, the Fair Hearing decision will not be expedited. Another hearing will be scheduled and the Fair Hearing will be decided using the usual time frame for deciding a Fair Hearing.