Provider Manual


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:

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

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.