It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

Choose Quality
GRIEVANCE AND COMPLAINT INFORMATION
Madison
Fiesta
Hispana
The health plan’s internal grievance
process is the required first step in
resolving member complaints. Each
health plan is required to have a
grievance process in place for members
to seek a change to an unfavorable
decision.
The most frequent types of grievances
filed by members in 2011 were related to:
• Non-covered or excluded benefits;
• Health plan service and
administration; and
• Prior authorizations.
An ETF complaint occurs when a
member contacts ETF about an issue for
input or investigation. The ombudsperson
review is the initial, optional step involved
in the administrative review process,
which allows members to appeal a plan
decision to ETF and subsequently to the
Group Insurance Board.
The three most frequent issues that
members contacted ETF about in 2011
were:
• Enrollment and eligibility;
• Billing and claim processing; and
• General program provision or
design.
In 2011, 855 members filed grievances
with their health plan or the pharmacy
benefit manager and 997 contacted ETF
to request assistance or file a complaint.
See the chart on the following page for
more complete information.
Decision Guide Page 65