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行政投诉

行政投诉是指除会员以外的任何人以书面或口头形式提出的与提供者、政府实体、机构或管理式护理组织相关的任何投诉。行政投诉不是请求重新授权服务或重新确定付款。会员不得提出行政投诉。

行政投诉可通过拨打免费提供商热线 877-615-8503 或以书面形式发送至：

Carelon
邮政信箱1840
蔓越莓镇，宾夕法尼亚州16066-1840
注意投诉调查员 要么

行政投诉也可传真至质量管理部 (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.

If the complainant is not satisfied with the initial resolution, s/he may file an appeal within five (5) business days of the receipt of the initial complaint resolution letter. The appeal may be initiated either by telephone on the toll-free provider line (877-615-8503), by FAX (855-287-8491), or in writing to the address above. Appeals of initial complaint resolutions will be reviewed by the Complaint Appeals Committee within thirty (30) calendar days of receipt of the appeal request by one of the Complaint Investigators. The Complaint Appeals Committee will be made up of the Director of Provider Relations, the Carelon Complaint Investigator, the Carelon Quality Management Director, a member of Carelon Senior Management or an Account Executive, the Medical Director and a Carelon Provider Field Coordinator. If the complaint involves an issue or issues concerning services rendered to a HealthChoices member, the Administrator or Administrator designee from the member’s county of residence will be invited to participate on the Complaint Appeals Committee.

投诉人将在会议召开前至少十 (10) 个日历日收到有关投诉上诉委员会会议的日期和时间的通知。如果投诉人愿意，他们将有机会在会议的前三十 (30) 分钟内出席委员会会议。陪同投诉人出庭的任何和所有个人都必须事先获得委员会的批准。

投诉上诉委员会的决定是最终决定，并将在决议后五 (5) 个工作日内以书面形式作出。

所有行政投诉将由质量管理部门进行跟踪和分析。