Manual do Provedor

PROCESSO DE QUEIXA

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 Formulário de Liberação de Reclamações.

Para uma descrição detalhada dos processos de reclamação, reclamação e audiência justa, consulte ambos Apêndice H e Apêndice AA.