HOW TO
CONTACT NUMBERS
USE THIS BROCHURE
he Department of Health conducted a
Under the law, there are two types of appeal--
survey of members in health maintenance
complaints and grievances.
T
organizations and found that enrollees are generally happy with their managed care plans.
A grievance is defined in law as a denial of
coverage based on the medical necessity and
But if you aren’t happy with your managed care
appropriateness of a health care service and the
plan for some reason, here are the things you can
review will include input from physicians or
do to get your problem solved:
psychologists in a same or similar specialty as
First check your enrollee contract or member
handbook to see what is and what is not covered
by the plan. Then call the plan’s member services
would normally treat or manage the service being
denied. In order to be a grievance, the health care
service must also be a covered benefit.
department (numbers are in the front of this
A complaint is virtually every other type of problem
brochure) and tell them what you are concerned
you could have and the review of a complaint
about to give them a chance to solve the problem.
does not include physicians or psychologists.
Most of the time the plan will be able to solve
your problem over the phone.
If you do not get the solution you want, the
second step is to file a formal complaint or grievance
with your plan.
The process for reviewing a complaint and
grievance include two levels of review by the
plan and then a third level of external review.
The timeframes for each level of appeal are the
same whether a complaint or a grievance.
Plan Name
Health Partners of Philadelphia, Inc.
Coventry Health Care of PA, Inc.
AmeriChoice of Pennsylvania, Inc.
CIGNA HealthCare of Pennsylvania, Inc.
Aetna Health, Inc.
Geisinger Health Plan
Health Net of Pennsylvania, Inc.
HealthGuard of Lancaster, Inc.
First Priority Health
One Health Plan of PA Inc.
AmeriHealth HMO, Inc.
Keystone Health Plan East, Inc.
Keystone Health Plan Central, Inc.
Gateway Health Plan, Inc.
Three Rivers Health Plans, Inc.
UPMC Health Plan, Inc.
Keystone Health Plan West, Inc.
HealthAmerica Pennsylvania, Inc.
Toll Free Number
(800) 553-0784
(800) 727-9951
(800) 321-4462
(800) 320-0251
(800) 872-3862
(800) 447-4000
(800) 441-5741
(800) 822-0350
(800) 822-8753
(888) 999-8036
(800) 877-9829
(800) 227-3114
(800) 622-2843
(800) 392-1147
(800) 414-9025
(888) 876-2756
(800) 547-9378
(800) 788-8445
Local Phone Number
(215) 991-4063
(302) 995-6100
(215) 832-4500
(302) 797-3700
(484) 322-6250
(570) 271-5555
(267) 675-4742
(717) 560-9049
(570) 200-6521
(215) 832-1020
(215) 241-2015
(215) 241-2175
(717) 302-0200
(412) 255-4640
(412) 858-4000
(412) 454-7500
(412) 544-7000
(717) 540-4260
PENNSYLVANIA
MANAGED CARE
MEMBER
APPEALS GUIDE
HOW TO
CONTACT NUMBERS
USE THIS BROCHURE
he Department of Health conducted a
Under the law, there are two types of appeal--
survey of members in health maintenance
complaints and grievances.
T
organizations and found that enrollees are generally happy with their managed care plans.
A grievance is defined in law as a denial of
coverage based on the medical necessity and
But if you aren’t happy with your managed care
appropriateness of a health care service and the
plan for some reason, here are the things you can
review will include input from physicians or
do to get your problem solved:
psychologists in a same or similar specialty as
First check your enrollee contract or member
handbook to see what is and what is not covered
by the plan. Then call the plan’s member services
would normally treat or manage the service being
denied. In order to be a grievance, the health care
service must also be a covered benefit.
department (numbers are in the front of this
A complaint is virtually every other type of problem
brochure) and tell them what you are concerned
you could have and the review of a complaint
about to give them a chance to solve the problem.
does not include physicians or psychologists.
Most of the time the plan will be able to solve
your problem over the phone.
If you do not get the solution you want, the
second step is to file a formal complaint or grievance
with your plan.
The process for reviewing a complaint and
grievance include two levels of review by the
plan and then a third level of external review.
The timeframes for each level of appeal are the
same whether a complaint or a grievance.
Plan Name
Health Partners of Philadelphia, Inc.
Coventry Health Care of PA, Inc.
AmeriChoice of Pennsylvania, Inc.
CIGNA HealthCare of Pennsylvania, Inc.
Aetna Health, Inc.
Geisinger Health Plan
Health Net of Pennsylvania, Inc.
HealthGuard of Lancaster, Inc.
First Priority Health
One Health Plan of PA Inc.
AmeriHealth HMO, Inc.
Keystone Health Plan East, Inc.
Keystone Health Plan Central, Inc.
Gateway Health Plan, Inc.
Three Rivers Health Plans, Inc.
UPMC Health Plan, Inc.
Keystone Health Plan West, Inc.
HealthAmerica Pennsylvania, Inc.
Toll Free Number
(800) 553-0784
(800) 727-9951
(800) 321-4462
(800) 320-0251
(800) 872-3862
(800) 447-4000
(800) 441-5741
(800) 822-0350
(800) 822-8753
(888) 999-8036
(800) 877-9829
(800) 227-3114
(800) 622-2843
(800) 392-1147
(800) 414-9025
(888) 876-2756
(800) 547-9378
(800) 788-8445
Local Phone Number
(215) 991-4063
(302) 995-6100
(215) 832-4500
(302) 797-3700
(484) 322-6250
(570) 271-5555
(267) 675-4742
(717) 560-9049
(570) 200-6521
(215) 832-1020
(215) 241-2015
(215) 241-2175
(717) 302-0200
(412) 255-4640
(412) 858-4000
(412) 454-7500
(412) 544-7000
(717) 540-4260
PENNSYLVANIA
MANAGED CARE
MEMBER
APPEALS GUIDE
t is best to send a written complaint or grievance
I
If you disagree with the plan’s classification of your
The decision letter will tell you how to appeal if
Third level complaints – You have 15 calendar
to the plan. The plan must accept an oral
appeal as either a complaint or a grievance, you
you are not satisfied with the plan’s response.
days from the day you get the second level
complaint but is only required to accept an oral
can contact the Pennsylvania Department of
IMPORTANT – You will have only 15 calendar days
decision letter to send a third level appeal letter
grievance if you cannot write or have a language
Health, Monday through Friday, from 8 am to 5 pm
from the time you get the decision letter to file a
to the Pennsylvania Department of Health or the
barrier. Sending your appeal in writing is the best
at 1-888-466-2787 (toll free) or 717-787-5193.
third level appeal.
Pennsylvania Insurance Department. Both agen-
48% of the time the plan overturns the previous denial.
way to make sure your concerns are documented
The Department will investigate and make a deci-
cies can process complaints and we coordinate
10% of first level complaints are appealed to the second level of appeal.
in your own words. Be sure to include in your
sion about whether or not your appeal should be
letter what you want the plan to do to fix
processed as a complaint or a grievance
the problem.
Third Level Grievances – When you want to file a
third level grievance, you notify the managed care
plan. The plan can charge a filing fee of up to $25.
with each other so that your case is reviewed by
the most appropriate agency. It doesn’t matter
which agency you send it to, we will transfer the
COMPLAINTS
An average of 13,650 level one complaints are filed statewide each year.
43% of the time the plan overturns the second level denial.
In 2001, the Pennsylvania Department of Health processed 137 third level complaints.
At the first level, your appeal will be reviewed by
The plan will then contact the Pennsylvania
The plan will send you a confirmation that it got
the plan within 30 calendar days and the plan has
Department of Health. The Department will assign
your appeal and the plan will tell you in the
5 business days after that to send you a written
the case to one of nine companies certified by the
confirmation if your appeal has been classified
decision. The decision letter will tell you how to
Department to process third level grievances. The
as a complaint or a grievance. Just because
file a second level appeal if you are not satisfied
grievance review company will send your case file
Expedited Appeals – If your life health or ability
something is medically necessary for you, doesn’t
with the plan’s first level decision.
to an independent physician or psychologist for
to regain maximum function is in jeopardy and
review. There are no hearings, meetings or discus-
your physician will put that in writing, you can
sions at this level. The reviewer will consider the
request an expedited appeal by the health plan.
documentation that has been submitted by you
In an expedited appeal, there is only one level of
and the plan. If you have new information you
review and it happens with 48 hours. Expedited
want to add for review, you must send it to the
appeals are designed for people in life-threatening
43% of the time the plan overturns the second level denial.
plan first and the plan will forward it to the
situations and should only be utilized in very
In 2001, there were 165 third level grievances.
grievance review company for consideration.
serious circumstances.
make your appeal a grievance. A grievance is when
there is disagreement over what is medically
necessary and appropriate for your condition and
that is why a physician or psychologist is part
of the review process. A complaint is when there
is no disagreement about what is medically
necessary for you but whether or not the plan
has to cover the service.
For example, the number of physical therapy
visits is limited, but the member wants
more visits.
The health plan would consider the appeal
a complaint because the member is requesting
more coverage than allotted by the contract.
The second level appeal will give you the
opportunity to attend a hearing to present your
concerns to a review committee. You can attend
in person or via telephone conference call.
The committee will listen to your side and may
ask you questions. Any documentation you want
the committee to consider should be sent in
advance of the meeting so they can read it
before hearing.
The plan has 45 calendar days to hold the hearing
and an additional 5 business days after that to
send the decision letter.
You will get a written decision from the grievance
review company within 60 calendar days.
case if appropriate and you will be notified. You
23% of the third level complaints were decided in full or in part for the enrollee.
will get a written decision from the Department
within 60 calendar days.
GRIEVANCES
An average of 6,320 level one grievances are filed statewide each year.
37% of the time the plan overturns the previous denial.
13% of grievances go to the second level of appeal.
42% of the third level grievances were decided in full or in part for the enrollee.
t is best to send a written complaint or grievance
I
If you disagree with the plan’s classification of your
The decision letter will tell you how to appeal if
Third level complaints – You have 15 calendar
to the plan. The plan must accept an oral
appeal as either a complaint or a grievance, you
you are not satisfied with the plan’s response.
days from the day you get the second level
complaint but is only required to accept an oral
can contact the Pennsylvania Department of
IMPORTANT – You will have only 15 calendar days
decision letter to send a third level appeal letter
grievance if you cannot write or have a language
Health, Monday through Friday, from 8 am to 5 pm
from the time you get the decision letter to file a
to the Pennsylvania Department of Health or the
barrier. Sending your appeal in writing is the best
at 1-888-466-2787 (toll free) or 717-787-5193.
third level appeal.
Pennsylvania Insurance Department. Both agen-
48% of the time the plan overturns the previous denial.
way to make sure your concerns are documented
The Department will investigate and make a deci-
cies can process complaints and we coordinate
10% of first level complaints are appealed to the second level of appeal.
in your own words. Be sure to include in your
sion about whether or not your appeal should be
letter what you want the plan to do to fix
processed as a complaint or a grievance
the problem.
Third Level Grievances – When you want to file a
third level grievance, you notify the managed care
plan. The plan can charge a filing fee of up to $25.
with each other so that your case is reviewed by
the most appropriate agency. It doesn’t matter
which agency you send it to, we will transfer the
COMPLAINTS
An average of 13,650 level one complaints are filed statewide each year.
43% of the time the plan overturns the second level denial.
In 2001, the Pennsylvania Department of Health processed 137 third level complaints.
At the first level, your appeal will be reviewed by
The plan will then contact the Pennsylvania
The plan will send you a confirmation that it got
the plan within 30 calendar days and the plan has
Department of Health. The Department will assign
your appeal and the plan will tell you in the
5 business days after that to send you a written
the case to one of nine companies certified by the
confirmation if your appeal has been classified
decision. The decision letter will tell you how to
Department to process third level grievances. The
as a complaint or a grievance. Just because
file a second level appeal if you are not satisfied
grievance review company will send your case file
Expedited Appeals – If your life health or ability
something is medically necessary for you, doesn’t
with the plan’s first level decision.
to an independent physician or psychologist for
to regain maximum function is in jeopardy and
review. There are no hearings, meetings or discus-
your physician will put that in writing, you can
sions at this level. The reviewer will consider the
request an expedited appeal by the health plan.
documentation that has been submitted by you
In an expedited appeal, there is only one level of
and the plan. If you have new information you
review and it happens with 48 hours. Expedited
want to add for review, you must send it to the
appeals are designed for people in life-threatening
43% of the time the plan overturns the second level denial.
plan first and the plan will forward it to the
situations and should only be utilized in very
In 2001, there were 165 third level grievances.
grievance review company for consideration.
serious circumstances.
make your appeal a grievance. A grievance is when
there is disagreement over what is medically
necessary and appropriate for your condition and
that is why a physician or psychologist is part
of the review process. A complaint is when there
is no disagreement about what is medically
necessary for you but whether or not the plan
has to cover the service.
For example, the number of physical therapy
visits is limited, but the member wants
more visits.
The health plan would consider the appeal
a complaint because the member is requesting
more coverage than allotted by the contract.
The second level appeal will give you the
opportunity to attend a hearing to present your
concerns to a review committee. You can attend
in person or via telephone conference call.
The committee will listen to your side and may
ask you questions. Any documentation you want
the committee to consider should be sent in
advance of the meeting so they can read it
before hearing.
The plan has 45 calendar days to hold the hearing
and an additional 5 business days after that to
send the decision letter.
You will get a written decision from the grievance
review company within 60 calendar days.
case if appropriate and you will be notified. You
23% of the third level complaints were decided in full or in part for the enrollee.
will get a written decision from the Department
within 60 calendar days.
GRIEVANCES
An average of 6,320 level one grievances are filed statewide each year.
37% of the time the plan overturns the previous denial.
13% of grievances go to the second level of appeal.
42% of the third level grievances were decided in full or in part for the enrollee.
t is best to send a written complaint or grievance
I
If you disagree with the plan’s classification of your
The decision letter will tell you how to appeal if
Third level complaints – You have 15 calendar
to the plan. The plan must accept an oral
appeal as either a complaint or a grievance, you
you are not satisfied with the plan’s response.
days from the day you get the second level
complaint but is only required to accept an oral
can contact the Pennsylvania Department of
IMPORTANT – You will have only 15 calendar days
decision letter to send a third level appeal letter
grievance if you cannot write or have a language
Health, Monday through Friday, from 8 am to 5 pm
from the time you get the decision letter to file a
to the Pennsylvania Department of Health or the
barrier. Sending your appeal in writing is the best
at 1-888-466-2787 (toll free) or 717-787-5193.
third level appeal.
Pennsylvania Insurance Department. Both agen-
48% of the time the plan overturns the previous denial.
way to make sure your concerns are documented
The Department will investigate and make a deci-
cies can process complaints and we coordinate
10% of first level complaints are appealed to the second level of appeal.
in your own words. Be sure to include in your
sion about whether or not your appeal should be
letter what you want the plan to do to fix
processed as a complaint or a grievance
the problem.
Third Level Grievances – When you want to file a
third level grievance, you notify the managed care
plan. The plan can charge a filing fee of up to $25.
with each other so that your case is reviewed by
the most appropriate agency. It doesn’t matter
which agency you send it to, we will transfer the
COMPLAINTS
An average of 13,650 level one complaints are filed statewide each year.
43% of the time the plan overturns the second level denial.
In 2001, the Pennsylvania Department of Health processed 137 third level complaints.
At the first level, your appeal will be reviewed by
The plan will then contact the Pennsylvania
The plan will send you a confirmation that it got
the plan within 30 calendar days and the plan has
Department of Health. The Department will assign
your appeal and the plan will tell you in the
5 business days after that to send you a written
the case to one of nine companies certified by the
confirmation if your appeal has been classified
decision. The decision letter will tell you how to
Department to process third level grievances. The
as a complaint or a grievance. Just because
file a second level appeal if you are not satisfied
grievance review company will send your case file
Expedited Appeals – If your life health or ability
something is medically necessary for you, doesn’t
with the plan’s first level decision.
to an independent physician or psychologist for
to regain maximum function is in jeopardy and
review. There are no hearings, meetings or discus-
your physician will put that in writing, you can
sions at this level. The reviewer will consider the
request an expedited appeal by the health plan.
documentation that has been submitted by you
In an expedited appeal, there is only one level of
and the plan. If you have new information you
review and it happens with 48 hours. Expedited
want to add for review, you must send it to the
appeals are designed for people in life-threatening
43% of the time the plan overturns the second level denial.
plan first and the plan will forward it to the
situations and should only be utilized in very
In 2001, there were 165 third level grievances.
grievance review company for consideration.
serious circumstances.
make your appeal a grievance. A grievance is when
there is disagreement over what is medically
necessary and appropriate for your condition and
that is why a physician or psychologist is part
of the review process. A complaint is when there
is no disagreement about what is medically
necessary for you but whether or not the plan
has to cover the service.
For example, the number of physical therapy
visits is limited, but the member wants
more visits.
The health plan would consider the appeal
a complaint because the member is requesting
more coverage than allotted by the contract.
The second level appeal will give you the
opportunity to attend a hearing to present your
concerns to a review committee. You can attend
in person or via telephone conference call.
The committee will listen to your side and may
ask you questions. Any documentation you want
the committee to consider should be sent in
advance of the meeting so they can read it
before hearing.
The plan has 45 calendar days to hold the hearing
and an additional 5 business days after that to
send the decision letter.
You will get a written decision from the grievance
review company within 60 calendar days.
case if appropriate and you will be notified. You
23% of the third level complaints were decided in full or in part for the enrollee.
will get a written decision from the Department
within 60 calendar days.
GRIEVANCES
An average of 6,320 level one grievances are filed statewide each year.
37% of the time the plan overturns the previous denial.
13% of grievances go to the second level of appeal.
42% of the third level grievances were decided in full or in part for the enrollee.
HOW TO
CONTACT NUMBERS
USE THIS BROCHURE
he Department of Health conducted a
Under the law, there are two types of appeal--
survey of members in health maintenance
complaints and grievances.
T
organizations and found that enrollees are generally happy with their managed care plans.
A grievance is defined in law as a denial of
coverage based on the medical necessity and
But if you aren’t happy with your managed care
appropriateness of a health care service and the
plan for some reason, here are the things you can
review will include input from physicians or
do to get your problem solved:
psychologists in a same or similar specialty as
First check your enrollee contract or member
handbook to see what is and what is not covered
by the plan. Then call the plan’s member services
would normally treat or manage the service being
denied. In order to be a grievance, the health care
service must also be a covered benefit.
department (numbers are in the front of this
A complaint is virtually every other type of problem
brochure) and tell them what you are concerned
you could have and the review of a complaint
about to give them a chance to solve the problem.
does not include physicians or psychologists.
Most of the time the plan will be able to solve
your problem over the phone.
If you do not get the solution you want, the
second step is to file a formal complaint or grievance
with your plan.
The process for reviewing a complaint and
grievance include two levels of review by the
plan and then a third level of external review.
The timeframes for each level of appeal are the
same whether a complaint or a grievance.
Plan Name
Health Partners of Philadelphia, Inc.
Coventry Health Care of PA, Inc.
AmeriChoice of Pennsylvania, Inc.
CIGNA HealthCare of Pennsylvania, Inc.
Aetna Health, Inc.
Geisinger Health Plan
Health Net of Pennsylvania, Inc.
HealthGuard of Lancaster, Inc.
First Priority Health
One Health Plan of PA Inc.
AmeriHealth HMO, Inc.
Keystone Health Plan East, Inc.
Keystone Health Plan Central, Inc.
Gateway Health Plan, Inc.
Three Rivers Health Plans, Inc.
UPMC Health Plan, Inc.
Keystone Health Plan West, Inc.
HealthAmerica Pennsylvania, Inc.
Toll Free Number
(800) 553-0784
(800) 727-9951
(800) 321-4462
(800) 320-0251
(800) 872-3862
(800) 447-4000
(800) 441-5741
(800) 822-0350
(800) 822-8753
(888) 999-8036
(800) 877-9829
(800) 227-3114
(800) 622-2843
(800) 392-1147
(800) 414-9025
(888) 876-2756
(800) 547-9378
(800) 788-8445
Local Phone Number
(215) 991-4063
(302) 995-6100
(215) 832-4500
(302) 797-3700
(484) 322-6250
(570) 271-5555
(267) 675-4742
(717) 560-9049
(570) 200-6521
(215) 832-1020
(215) 241-2015
(215) 241-2175
(717) 302-0200
(412) 255-4640
(412) 858-4000
(412) 454-7500
(412) 544-7000
(717) 540-4260
PENNSYLVANIA
MANAGED CARE
MEMBER
APPEALS GUIDE