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Grievances and appeals

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a grievance or complaint. And if you’re unhappy with a decision we made, you can file an appeal. 

 

To learn more, just check your member handbook.

Help us better serve you

Help us better serve you

A grievance: You’re unhappy with the quality of care or services you received from:

 

  • One of your doctors, like your primary care physician (PCP)

  • One of your providers, like a pharmacy or hospital

  • Your health plan 

 

A complaint: You don’t agree with a decision we made about coverage. 

 

An appeal: You want us to review and change a decision we made about your coverage. You’ll get a letter from us if we reduce, stop or can’t approve service. We call this an Adverse Benefit Determination. Then, you can file an appeal. Your doctor or someone else can file an appeal for you. 

File your grievance or appeal

I want to file a grievance, complaint or appeal

 

You have options for filing a grievance, complaint or appeal. And we’re here to help you through the process.

 

What happens next?

What happens next?

Grievances

 

There's no time limit for filing a grievance. We’ll send you a letter after we get your grievance. Then, we’ll send our decision in another letter within 30 days.

 

Complaints

 

When you don’t agree with a benefit decision we made about coverage, we transfer your complaint to Appeals.

 

Appeals


You can file an appeal after you receive an Adverse Benefit Determination letter (denial). This letter says we won’t cover the service you want. You’ll want to send your appeal:

 

  • Within 60 days of getting your denial letter

  • Within 10 calendar days of getting your denial letter — if your appeal is for ongoing benefits that we had already approved, that you were already getting and that haven’t expired 

 

We’ll send you a letter after we get your appeal. Here are some timelines to note:

 

  • Within 5 days: We’ll send you a letter to let you know we received your appeal and we’re working on it.

  • Within 30 days (standard): We’ll review your appeal in this time frame if we have all the info we need.

  • Up to 44 days: The appeal may take this much time if you need more time to share info or if we need more time to gather info.

  • Within 72 hours (expedited): Sometimes, we’ll review an appeal in this time frame. This happens when your doctor feels your condition is serious. 

Once we review your appeal, you’ll receive a letter with our decision. 

More help with grievances, complaints and appeals

If you need more help or don’t agree with our appeal decision, here are some options.