提供者手册

申诉程序

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 申诉发布表.

有关投诉、申诉和公平听证程序的详细说明，请参阅两者 附录H 和 附录AA.