Common Questions about Grievances & Appeals


Q: Who can file a complaint (grievance), appeal or request for hearing?

A: You may file or an authorized representative may file on your behalf. You must identify your authorized representative in writing.

Q: What actions can I appeal?

A: You can appeal any denial, reduction, suspension or termination of service, or denial of claim payment for a non-covered service. This can include a failure to act timely. These are called "actions". Examples include a denial of a request for surgery, a denial of a request for a wheelchair, a reduction in physical therapy days, etc.

Q: What are the time frames for filing an appeal?

A: Your appeal must be filed (received) no later than 60 days from the notice of action. The notice of action describes the reasons for the action, and tells you how to file an appeal.

Q: What if I need help filing my appeal?

A: Your health plan is required to provide reasonable assistance, including information on the process.

Q: Who will make the decision on my appeal?

A: A qualified health care professional will make decisions on medical decisions. The person who reviews the appeal cannot be the same person who made the original decision.

Q: What is a grievance?

A: A complaint about anything that does not involve an "action" as described in question number 2 above. The health plan's decision is final and will not be reviewed through a state fair hearing.

Q: What do you mean when you say "seriously jeopardizing one's health?"

A: This means serious harm to your life or health or your ability to attain, maintain or regain maximum function.