PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If you have any of these kinds of problems, you can “make a complaint” Quality of your medical care • Are you unhappy with the quality of the care you have received (including care in the hospital)? Respecting your privacy • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confi dential? Disrespect, poor customer service, or other negative behaviors • Has someone been rude or disrespectful to you? • Are you unhappy with how our Customer Service has treated you? • Do you feel you are being encouraged to leave the plan? Waiting times • Are you having trouble getting an appointment, or waiting too long to get it? • Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Customer Service or other staff at the plan? Cleanliness � Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room. • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s offi ce? Information you get from us • Do you believe we have not given you a notice that we are required to give? • Do you think written information we have given you is hard to understand? Th e next page has more examples of possible reasons for making a complaint 189
190 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Possible complaints (continued) These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals Th e process of asking for a coverage decision and making appeals is explained in sections 4-9 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples: • If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will not, you can make a complaint. • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint. • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint. • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint. Section 10.2 The formal name for “making a complaint” is “fi ling a grievance” Legal Terms What this section calls a “complaint” is also called a “grievance.” Another term for “making a complaint” is “fi ling a grievance.” Another way to say “using the process for complaints” is “using the process for fi ling a grievance.”
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Page 221: 55 Water Street, New York, New York
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PPO II - EmblemHealth

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