Complaint Appeals. If your complaint regarding an administrative operation or matter or a post-service claim is not resolved to your satisfaction, then within 60 calendar days after receiving notice that your complaint was wholly or partially denied, you or your authorized representative may request an appeal. Your appeal can be submitted to PIC in writing, along with any issues, comments, and additional information as appropriate. You have the right to present written evidence and telephonic testimony as part of the appeals process for any appeal that involves a medical determination in its resolution, but only with respect to the resolution of the medical determination aspect. Within 30 calendar days after any written appeal requiring a medical determination in its resolution is received by PIC, you will receive written notice of PIC’s decision, including the specific reasons for it and the procedure for requesting an external review to the extent external review is required by law. Within 30 calendar days after any other written appeal is received by PIC, you will receive written notice of PIC’s decision, including the specific reasons for it. These time periods may be extended for up to an additional 14 calendar days if you agree.
Complaint Appeals a) The Contractor's procedures regarding Enrollee Complaint Appeals shall include the following:
Complaint Appeals. If you disagree with a decision we made about your complaint, you or someone you trust can file a complaint appeal with the plan. How to make a complaint appeal: If you are not satisfied with what we decide, you have at least 60 business days after hearing from us to file an appeal; • You can do this yourself or ask someone you trust to file the appeal for you; • The appeal must be made in writing. If you make an appeal by phone, it must be followed up in writing. After your call, we will send you a form, which is a summary of your phone appeal. If you agree with our summary, you must sign and return the form to us. You can make any needed changes before sending the form back to us. What happens after we get your complaint appeal? After we get your complaint appeal, we will send you a letter within 15 workdays. The letter will tell you: • who is working on your complaint appeal • how to contact this person • if we need more information Your complaint appeal will be reviewed by one or more qualified people at a higher level than those who made the first decision about your complaint. If your complaint appeal involves clinical matters your case will be reviewed by one or more qualified health professionals, with at least one clinical peer reviewer, that were not involved in making the first decision about your complaint. If we have all the information we need you will know our decision in 30 workdays. If a delay would risk your health, you will get our decision in 2 work days of when we have all the information we need to decide the appeal. You will be given the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at 0-000-000-0000.
Complaint Appeals. 1. Upon receipt of a Member’s written appeal of a Complaint, HMO shall provide the Member with an acknowledgment letter within 5 business days. This letter shall contain the procedures governing appeals before the Appeal Panel including the date and location for the Member to appear before the Appeal Panel. The appeal process gives the Member the opportunity to appear in person or by telephone before the Appeal Panel or address the Member's issues through a written appeal to the Appeal Panel. The Member shall be notified of the Member’s right to have an uninvolved HMO representative available to assist the Member in understanding the appeal process. No less than 5 business days prior to the Member's appearing before the Appeal Panel, the Member will receive a copy of any documentation to be presented by the HMO staff; the specialization of Physicians or Providers consulted during the review; and the name and affiliation of all HMO representatives on the Appeal Panel. The Member may respond to this information for the Appeal Panel to consider in the HMO's deliberations.
