1. What can I do if I disagree with my HMO or one of its providers?

Grievance: HMOs and their providers (doctors, hospitals, etc.) make decisions affecting your health care all the time. Under Pennsylvania law, every HMO must have a grievance process for resolving any dispute that you may have with your HMO or its providers. These disputes may be about payment, about the way you have been treated, or about any other problem. The grievance process is more formal than making an inquiry or a complaint with the HMO.

Fair Hearing: Federal law requires DPW to offer an administrative hearing (called a "fair hearing") to anyone whose cash, food stamps, medical assistance or other services are denied, reduced or terminated. Any HMO member whose health services have been denied, reduced or terminated also has the right to request a "fair hearing" from DPW. You can file a grievance and request a fair hearing.

Also, you may have a legal claim for malpractice, discrimination, breach of contract etc. To determine if you have a legal claim, consult an attorney immediately. 

2. How do an inquiry, a complaint and a grievance differ?

inquiry is your request for information or administrative service (e.g. asking for your doctor's phone number), or a contact to the HMO to give an opinion. If you donít ask the HMO to do something, you are making an inquiry.

A complaint is an problem which you ask the HMO to resolve informally. Complaints can be made to the HMO orally or in writing. If the HMO canít resolve your problem within 30 days, it automatically becomes a grievance.

A grievance is a problem for which you seek a formal resolution. By filing a grievance, you take advantage of certain legal rights, described below. If you want your HMO to do something it is often best to file a grievance.

3. How do I know if someone decided something about my care?

Denials, reductions, or terminations of service or coverage should be in writing from the HMO or its subcontractor, telling you: the reason for the denial, your appeal rights, and the right to receive continuing services pending the outcome of a fair hearing, if you request one in 10 days. Notices must be accessible for persons with vision problems or who do not speak English. Other decisions about your health care may not be in writing. You may learn about them from your doctor or someone else. You still have the right to make a grievance or request a fair hearing. (See 9. next page)

4. How do I make a grievance?

Contact your HMO. Look in your member handbook to see whom to contact, or call the HMOís toll-free phone hotline (24 hour per day, 7 days per week). If you don't know the member Hotline, call Benova at 1-800-440-3989. Grievances can be oral or written. It is best to put your problem in writing and write "Grievance" at the top. Explain what happened, why you disagree, and what you want done to fix the problem.

5. What happens next?

The HMO must have one or more of its employees, who was not previously involved, review your case and make another decision. This is called a "first level grievance review." It should take place within 30 days. You can send in written materials for consideration, and you have a right to assistance from an HMO staff person. A written decision must be made within 10 working days. It must state your appeal rights.

6. If I donít like the first level review decision, what do I do?

You should not give up. If you appeal again, the HMO must give you a "second level grievance review." Here, the dispute is decided by a committee, including an MA recipient.

This second level review is more formal, and you have a right to come and give your side and ask questions of the HMO. You also have a right to be represented by someone whom you choose or by an HMO staff person. The HMO must hold the meeting conveniently, within 30 days of your request. You must get 15 days advance notice, and a copy of the procedures.

The meeting must either be recorded or minutes kept in case there is a need for further review (See #7, below). The HMO must give a written decision in 10 working days.

> 7. What if Iím still not satisfied after the second level review?

Now you have the opportunity for the Health Department to review your problem and make a decision. You must file an appeal within 30 days to:

Bureau of Health Financing and Program Development
Pennsylvania Department of Health
Room 1026, Health and Welfare Building
P.O. Box 90
Harrisburg, PA 17108-0090 Phone: 717-787-5193

8. What if I have an urgent or emergency problem?

If you believe that adverse medical consequences will arise in the near future from an HMOís failure to provide needed and covered services, you should let the HMO know right away. The HMO must arrange to have the grievance reviewed by its Medical Director within 48 hours. The Medical Director must inform you of his/her decision in writing. Appeals from the Medical Directorís decision begin at the second level.

9. Can I file for a fair hearing?

Yes. Federal law requires DPW to offer a fair hearing if a claim for medical assistance is denied or not acted upon promptly. And a hearing is available if action is taken to suspend, terminate or reduce services. Probably the most important advantage to filing for a fair hearing is the rule that the HMO must provide continued services pending a fair hearing decision where the enrollee has filed a timely (within 10 days) appeal of a reduction or termination of any ongoing service. You can file both a grievance and a fair hearing request, at the same time.

10. How do I file for a fair hearing?

Write your name, address, telephone number, the name of your HMO, your HMO subscriber number, and what you are disputing on a piece of paper. Write "appeal" at the top of the paper, and mail it to:

Department of Public Welfare
Office of Medical Assistance Programs
HealthChoices Program
PO Box 2675
Harrisburg, PA 17105-2675

11. Where can I turn for help with my appeal?

You may qualify for free independent help from such places as your local legal services program or the Pennsylvania Health Law Project (1-800-274-3258).

12. Can I quit my HMO, or change my Primary Care Physician (PCP)?

You can switch your pcp or your plan for any reason or for no reason at all. However, there is a time delay, and the new plan or doctor may not fix the problem.

Prepared 12/13/96 by the Pennsylvania Health Law Project