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What to do when you disagree with your HMO
The grievance process is the way people in HMOs and in certain PPOs
(called "gatekeeper" PPOs) have to contest decisions about the health services
their HMO will cover or their HMO doctor will authorize. Therefore, it
is extremely important that people in HMO's/PPOs be familiar with their
rights under their HMO's grievance process. Each HMO and "gatekeeper" PPO
is required under State law to have a grievance process for persons enrolled
in that HMO/PPO ("subscribers") and to provide a copy of that process to
each subscriber annually. While there are variations in grievance processes
between HMOs, the PA Department of Health has set out certain requirements
with which all HMOs in Pennsylvania must comply. This memo explains those
Note: These requirements are set out at 28 Pa.Code 9.73 and in a memo from
the PA Dept. of Health dated 8/1/91. Unless stated otherwise, the requirements
set out below are found in the 8/1/91 memo.
Complaints vs. Grievances
When a person in an HMO/PPO wishes to contest a decision about their
health care, it is important they file a grievance rather than a complaint.
Complaints do not entitle a subscriber to any of the grievance rights set
out below. Unless the request or dispute is put in writing by the subscriber
with a clear indication that it is a grievance, the HMO/PPO may consider
it only to be a complaint. Therefore, any dispute from a subscriber should
be put in writing and should have the word "Grievance" at the top.
Levels of Grievances
A grievance is an opportunity for a subscriber to have his/her request
or dispute heard and decided by persons who were not directly involved
in making the disputed decision. These persons are called the "Grievance
Committee". HMOs may provide one or two levels of grievances which are
described below. If the subscriber goes through the levels of grievance
provided by his/her HMO/PPO, he or she can then take their grievance to
the Department of Health (also explained below). This memo also explains
special quicker procedures when the dispute involves a "medically pressing
1st Level Grievance
The subscriber has the right to submit written information and have
an "uninvolved" HMO/PPO staff person assist in that effort. [¤9.73(1(ii)
&(7)] However, the subscriber does not have the right to attend the
grievance committee (although HMOs have been urged by the Health Department
to allow this).
The Grievance Committee decides the grievance. It must be comprised
of one or more employees of the HMO/PPO who were not involved in the decision
being appealed and were not involved in handling the complaint, if any,
that preceded the grievance. The Committee should review the grievance
within 30 days.
The Grievance Committee must issue a written decision within 10 days
of the date it meets to review the grievance. If the Committee finds against
the subscriber, even partially, the written decision must contain:
the reasons for the Committee's decision;
the evidence or documentation relied upon; and
a statement regarding the subscriber's right to file a second level grievance,
the time limits for filing the 2nd level grievance & how to file that
2nd Level Grievance
Note: An HMO/PPO may chose to limit its grievance procedures to a single
level so long as that level complies with the 2nd level requirements set
HMOs should provide between 30 and 60 days from the date the 1st level
grievance decision is issued for an subscriber to file a 2nd level grievance.
The Grievance Committee hears and decides the grievance. Committee
members are appointed by the HMO's Board of Directors. One third of the
Committee members must be subscribers. [¤9.73(2)(ii)] Committee
members may not have any previous involvement in the decision being appealed
or the 1st level grievance.
Date/notice of hearing
HMOs must hold hearings at "mutually convenient times" The subscriber
must be notified of the date & time at least 15 days in advance. The
hearing should be held within 30 days.
Right to appear/ be represented
Unlike the 1st level grievance, subscribers have the right to appear
at the 2nd level grievance hearing and present their case. They also have
the right to be represented by a person of their choice, including a non-involved
HMO/PPO staff person. However, failure to appear is not grounds for dismissing
Right to question staff
The subscriber has the right to question HMO/PPO staff at the grievance
hearing concerning the dispute.
Disputes involving differing physician opinions
Where the subscriber has documentation from a physician contradicting the
opinion of his/her primary care physician or the HMO/PPO Medical Director,
the Grievance Committee cannot automatically assume the PCP or Medical
Director is correct. It must make an independent assessment.
The HMO/PPO must have written procedures for utilizing "informed consultants"
to resolve grievances. [¤9.73(2)(v)]
The written decision of the 1st level grievance must be the basis for deliberation.
If the HMO/PPO has an attorney to represent the staff making the decision
appealed from, it must also provide an attorney for the Grievance Committee
(but has no obligation to provide an attorney for the subscriber).
Written minutes or a tape recording of the hearing must be made.
The grievance Committee must render its decision within 10 working days
following the hearing.
The Committee must send a written decision to the subscriber which must
the evidence or documentation relied on by the Committee;
the rationale for its decision; and
a statement that the subscriber has the right to appeal to the Department
3rd Level Appeal- Dept. of Health
The subscriber has 30 days to file his/her appeal with the Dept. of
Health "unless extenuating circumstances are involved."
How to appeal
Appeals to the Dept. of Health are to be made in writing and mailed
Bureau of Health Care Financing
Room 1026 Health & Welfare Bldg.
Dept. of Health
PO Box 90
Harrisburg, PA 17108-0090
The Dept. of Health may hold its own hearing, require the HMO/PPO to
rehear the grievance to address specific issues or decide the case on the
documentation supplied by both sides.
Expedited grievances for "medically pressing issues"
When the dispute involves care which is alleged to be medically necessary
and "pressing" [not defined by the Dept. of Health], and the care has not
yet been provided, the HMO/PPO must render an initial decision approving
or denying the care in writing within a "reasonable time" which is defined
by the Department as 48 hours. If the subscriber appeals that decision,
the grievance would begin at the 2nd level.
Persons on Medical Assistance in HMOs
Persons on Medical Assistance in HMOs have all the rights set out above
and also have the right to file an appeal with the Department of Public
Welfare. There are also special rules that apply to grievances under the
"HealthChoices" program. To file an appeal with the Department of Public
Welfare, write your name, address and phone number, name of your HMO/PPO,
your HMO/PPO subscriber number and the decision you are disputing on a
piece of paper. Put "Appeal" at the top of the paper. Mail it to: Office
of Hearings and Appeals, Department of Public Welfare, 6th Flr. Bertolino
Bldg. PO Box 2675, Harrisburg, PA 17105
What to do for more help
The PA Health Law Project is available to advise and assist persons
with disabilities and persons on Medical Assistance in disputes with their
HMOs. You can reach us by calling 800-931-7457 or 800-274-3258. You can
also call the PA Department of Health, Bureau of Health Care Financing
(which licenses HMOs) at 888-466-2787.