Peach State Provider Office Manual - Peach State Health Plan ...

• To keep all your appointments. To be on time and cancel within twenty-four (24)hours if you cannot make it.• To treat your provider with dignity and respect.MEMBER GRIEVANCESA grievance is an expression of dissatisfaction with any aspect of Peach State’s or a provider'soperation, provision of healthcare services, activities, or behaviors, other than a Proposed Action.A member or member’s authorized representative may file a grievance either orally or in writing.Peach State will notify the member or authorized representative that the grievance has beenreceived in writing within 10 business days of receipt of the grievance. A provider cannot file agrievance on behalf of a member. Members or their authorized representative may file agrievance by contacting Member Services at: 1-800-704-1484 or by submitting written notificationto:Peach State Health PlanAppeals/Grievance Coordinator3200 Highlands Parkway SESuite 300Smyrna, GA 30082Peach State will respond to all issues raised by members within 90 calendar days of receipt of thegrievance. Should Peach State (with approval of DCH) or the member request additional time toresolve the grievance, Peach State will extend the resolution timeframe to 14 additional calendardays for resolution of the grievance.ADMINISTRATIVE REVIEWAn Administrative Review is the request for review of a Proposed Action. An Action is the denialor limited authorization of a requested service, including the type or level of service; the reduction,suspension, or termination of a previously authorized service; the denial, in whole or part ofpayment for a service; the failure to provide services in a timely manner, as defined by the Stateof Georgia; or the failure of Peach State to act within the time frames provided in 42 CFR438.408(b). The review may be requested by telephone or in writing; however oral requests foradministrative review within the standard timeframe must be confirmed in writing within 30 days ofthe date of the Proposed Action. Members may request that Peach State review the ProposedAction to verify if the right decision has been made.Who may file an Administrative Review?• Peach State member• Authorized representative of Peach State member• Provider acting on behalf of member (with written member consent)Requests for an Administrative Review must be made within thirty (30) calendar days from thedate of the Notice of Proposed Action. Under certain circumstances, members have the right torequest, within 10 days of the date of the Notice of Proposed Action, that benefits be continuedwhile an administrative review is pending. Peach State will send a written decision within fortyfive(45) calendar days after the request for an Administrative Review is received by PeachState, subject to an authorized extension of up to 14 days.Provider Services1-866-874-063302/22/2011114