Provider Manual

ADMINISTRATIVE COMPLAINTS

An administrative complaint is any complaint relevant to a provider, a governmental entity, an institution, or a Managed Care Organization that anyone other than a member presents, either in written or verbal form. An Administrative Complaint is not a request for a retro-authorization of service or a re-determination of payment. An Administrative Complaint may not be initiated by a member.

Administrative complaints may be initiated either by telephone on the toll-free provider line at 877-615-8503 or in writing addressed to:

Carelon
P.O. Box 1840
Cranberry Township, PA 16066-1840
Attention Complaint Investigator or

Administrative complaints may also be faxed to the Quality Management Department (855-287-8491).

Carelon will document and work to resolve all administrative complaints within thirty (30) calendar days of receipt. If a complaint cannot be handled at the first point of contact, it will be assigned to a Complaint Investigator to resolve the complaint in an expedient manner. A letter outlining the resolution of the initial complaint will be sent to the complainant when the resolution of the complaint is accomplished, or within five (5) business days after the initial thirty (30) calendar days allocated for the complaint resolution, whichever comes first.

If the complainant is not satisfied with the initial resolution, s/he may file an appeal within five (5) business days of the receipt of the initial complaint resolution letter. The appeal may be initiated either by telephone on the toll-free provider line (877-615-8503), by FAX (855-287-8491), or in writing to the address above. Appeals of initial complaint resolutions will be reviewed by the Complaint Appeals Committee within thirty (30) calendar days of receipt of the appeal request by one of the Complaint Investigators. The Complaint Appeals Committee will be made up of the Director of Provider Relations, the Carelon Complaint Investigator, the Carelon Quality Management Director, a member of Carelon Senior Management or an Account Executive, the Medical Director and a Carelon Provider Field Coordinator. If the complaint involves an issue or issues concerning services rendered to a HealthChoices member, the Administrator or Administrator designee from the member’s county of residence will be invited to participate on the Complaint Appeals Committee.

The Complainant will be notified of the date and time of the Complaint Appeals Committee meeting at least ten (10) calendar days in advance of the meeting. The Complainant will be given the opportunity to appear before the Committee for the first thirty (30) minutes of the meeting, should they so choose. Any and all individuals accompanying the Complainant at this appearance must receive prior approval by the Committee.

The decision of the Complaint Appeals Committee is final and will be rendered in writing within five (5) business days of the resolution.

All administrative complaints will be tracked by and trended by the Quality Management Department.