Provider Manual

GRIEVANCE PROCESS

A grievance is defined as a request by a member or member representative to have Carelon reconsider a decision solely concerning the medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered service. A provider may be involved and/or act on the member’s behalf if written authorization has been obtained from the member. This can be accomplished 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.