Provider Manual

GRIEVANCE PROCESS

A grievance is defined as a request by a member or advocate (family member or guardian) to reconsider a decision concerning the medical necessity and appropriateness of a health care service. A provider may request reconsideration on behalf of the member if written permission has been obtained from the member to do so by filling out the Grievance Release Form.

For a detailed description of the complaint, grievance, and fair hearing processes, please refer to both Appendix H and Appendix AA.