Complaints

What is a Complaint?

A complaint is when you tell us you are unhappy with Community Care or your provider, or you do not agree with a decision made by Community Care. Complaints may occur because of:

  1. A denial because the requested service is not a covered benefit;
  2. Failure of the BH-MCO to meet the required time frames for providing a service;
  3. Failure of the BH-MCO to decide a complaint or grievance within the specified time frames;
  4. A denial of payment after a service(s) has been delivered because the service(s) was provided without authorization by a provider not enrolled in the Pennsylvania Medical Assistance Program;
  5. A denial of payment after a service(s) has been delivered because the service is not a covered benefit.
  6. A denial of a member's request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial liabilities; or
  7. A member’s dissatisfaction with the BH-MCO or a provider.

What should I do if I have a complaint?

To file a complaint, contact Community Care.    

When should I file a First Level Complaint?

For complaint issues 1 – 6 above, your complaint must be filed within 60 calendar days of the incident complained of or the date you receive notice of the decision.

All other complaint issues may be filed at any time without any time limits.

When you contact Community Care to voice your dissatisfaction, it is considered a First Level Complaint. You can contact Community Care by phone, by fax, or in writing.

There is never any cost or fee to file a complaint.

What kind of help can I get with the complaint process?

If you need help filing your complaint, a Community Care staff person will help you. This person can assist you during the complaint process. You do not have to pay for the help of a staff person. He or she will not have been involved in any previous decision about your complaint.

You may also have a family member, friend, or other supportive person help you file your complaint. This person can also help you if you decide you want to attend the complaint review. At any time during the complaint process, you can have someone you know represent you or act on your behalf. Tell Community Care if you decide to have someone represent you. You will need to sign forms allowing that person to represent you in the complaint. Otherwise, we can only correspond with you.

You or the person you choose to represent you may ask Community Care for information we have about your complaint. You or the person you choose to represent you may submit any comments, documents, or other information relevant to your complaint to Community Care.

You do not need a lawyer to file a complaint. However, if you are interested in legal assistance, you can contact the Pennsylvania Legal Aid Network at 1-800-322-7572 (www.palegalaid.net), the Pennsylvania Health Law Project at 1-800-274-3258 (www.phlp.org), or call your local legal aid office.

Persons Whose Primary Language is Not English

If you ask for language interpreter services, Community Care will provide the services at no cost to you.

Si usted necesita interpretacion al Español, Community Care se lo dara gratis. Por favor llame a 1-866-229-3187.

Persons with Disabilities and Special Needs

If needed, Community Care will provide persons with disabilities with the following help in presenting complaints at no cost.

  • Providing sign language interpreters.
  • Providing information submitted by Community Care at the complaint review in an alternative format. The alternative format version will be given to you before the review.
  • Providing someone to help photocopy and present information at your complaint review.

What happens after I file a First Level Complaint?

Community Care staff will call you to discuss the details of your complaint and to tell you about the First Level Complaint process. Staff will also send you a letter including that information or, if we have not been able to reach you by phone, the letter will let you know that we received your complaint and tell you about the First Level Complaint process. You may ask Community Care to see information about your complaint. You may also send or tell us about information that may help with our complaint investigation. You can ask for assistance by calling Community Care member services for your county.

If your complaint is about any of the following five issues, you can attend the First Level Complaint review and/or file a Fair Hearing. If you do not attend, it will not affect our decision. You may also be able to get treatment continuation rights.

  1. Denial because the requested service is not a covered benefit;
  2. Failure of the BH-MCO to meet the required time frames for providing a service;
  3. Failure of the BH-MCO to decide a complaint or grievance within the specified time frames;
  4. Denial of payment after a service(s) has been delivered because the service(s) was provided without authorization by a provider not enrolled in the Pennsylvania Medical Assistance Program;
  5. Denial of payment after a service(s) has been delivered because the service is not a covered benefit;
  6. Denial of a member's request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial liabilities. 

For all complaint issues, a First Level Complaint Review Committee including one or more Community Care staff, who has not been involved in the issue you filed your complaint about, and who has relevant clinical experience if needed, will make a decision about your complaint. 

You can attend the Complaint review in person, by video conference, or by phone so that you can have an opportunity to present information. You do not have to attend. You can also present additional information in writing. If you do not attend the review meeting, the meeting will proceed, and it will not affect our decision.

Your complaint will be decided no more than 30 days after we receive it, and a letter will be mailed to you within those 30 days. This letter will tell you about our findings, the reason(s) for the decision, and the actions taken. It will also tell you how to file a Second Level Complaint if you do not agree with the decision.

What can I do if my health is at immediate risk?

If your doctor or psychologist believes that the usual time frames for deciding your complaint will harm your health, then you, your doctor, or your psychologist can call, fax, or write to Community Care to ask that your complaint be decided faster. Complaints completed within quicker than usual timelines are known as Expedited Complaints.

Your provider must then submit a certification within 72 hours telling us the reasons why the expedited review is needed. Otherwise, the complaint will be decided within the usual time frame of 30 days.

The expedited review process is bound by the same rules and procedures as the complaint review process with the exception of time frames. The Committee will make a decision about your complaint and inform you of the decision within 48 hours of receiving your doctor or psychologist's letter explaining how the usual time frame of 30 days for deciding your complaint will harm your health. You will also receive a letter telling you the reason(s) for the decision. It will tell you how to ask for an Expedited Level Two Complaint and/or Expedited External review if you do not like the decision.

What if I do not like Community Care's decision?

If you are not happy with Community Care’s First Level complaint decision, you may file a Second Level Complaint with Community Care.

When should I file a Second Level Complaint?

You must file your Second Level Complaint within 45 days of the date you get the First Level Complaint decision letter. Use the same address, fax or phone number you used to file your First Level Complaint.

What happens after I file a Second Level Complaint?

Community Care staff will call you to discuss the details of your second level complaint and to tell you about the Second Level Complaint process. Staff will also send you a letter including that information or, if we have not been able to reach you by phone, the letter will let you know that we received your Level 2 Complaint and tell you about the Second Level Complaint process.

  • You may ask Community Care to see information about your complaint.
  • You may send or tell us about information that may help with our further investigation of your complaint.
  • You can attend the meeting of the Second Level Complaint Review Committee or be included by phone or video conference; and, you will be given at least 15 days advanced notice. Community Care will contact you to ask if you want to come to the meeting and to ask whether you will consent to having the meeting audio-recorded. You do not have to attend if you do not want to. If you do not attend, it will not affect our decision.
  • Any provider or other person can only attend the meeting with your permission.
  • The Second Level Complaint Review Committee will have three people on it. At least one member on the committee will not be an employee of Community Care, and another will have clinical experience relevant to your complaint process. The members of the committee will not have been involved in the issue you filed your complaint about.
  • The committee will make a decision no more than 45 days from the date Community Care received your Second Level Complaint and a decision letter will be mailed to you within those 45 days. This letter will tell you the reason(s) for the decision and any further actions taken. It will also tell you how to ask for an External Complaint Review if you do not agree with the decision of the committee.

What if I still do not agree with the decision?

If you are not happy with the Second Level Complaint decision, you may ask for an External Complaint Review that will be conducted by the Pennsylvania Department of Health or the Pennsylvania Insurance Department.

You must ask for this external review of your complaint within 10 days of the date you receive the Second Level Complaint decision letter. If you ask, Community Care will help you put your External Complaint in writing. You must send your request for an External Complaint Review in writing to either:

Pennsylvania Department of Health Bureau of Managed Care
Health & Welfare Building, Room 912
625 Forster Street, Harrisburg, PA 17120
Phone: 1-888-466-2787 | Fax: 717-705-0947 | Relay Service: 1-800-654-5984

or

Pennsylvania Insurance Department Bureau of Consumer Services
1321 Strawberry Square, Harrisburg, PA 17120
Phone: 1-877-881-6388

If you send your request to the wrong department, it will be sent to the correct department. The Pennsylvania Department of Health or the Pennsylvania Insurance Department will get your complaint information from Community Care. You may also send them any other information that may help with the External Complaint Review. A decision letter will be sent to you after the decision is made. This letter will tell you the reason(s) for the decision and what you can do if you do not agree with the decision.

What is a Fair Hearing?

In some cases, you or your representative can ask the Department of Human Services (DHS) to hold a hearing because you are unhappy about, or do not agree with, something that Community Care did or did not do. These hearings are called DHS Fair Hearings. You can ask for a Fair Hearing at any point in the complaint process when you file a complaint regarding any of the issues listed 1 – 6 above.

How do I ask for a Fair Hearing?

You must ask for a Fair Hearing in writing within 120 days from the mail date on the written notice of the complaint decision. Send your request to:

Department of Human Services
Office of Mental Health and Substance Abuse Services
Division of Quality Management
Commonwealth Towers, 12th Floor
P. O. Box 2675
Harrisburg, PA 17105-2675

Or fax your request for a Fair Hearing to: 717-772-7827.

Your request for a Fair Hearing should include all of the following information:

  • Your name
  • Your Social Security number
  • Your date of birth
  • A phone number where you can be reached during the day
  • A statement of whether you want to have the fair hearing in person or by phone
  • A copy of all letters you have received about the issue you are requesting your fair hearing for

What happens after I ask for a Fair Hearing?

You will get a letter from the Department of Human Services telling you where the hearing will be held and the date and time of the hearing. You should receive this letter at least 10 days before the date of the hearing.

You may come to the Fair Hearing or be included by phone. A family member, friend, lawyer, or other person may help you during the Fair Hearing.

Community Care will also go to your Fair Hearing to explain why we made the decision or explain what happened. If you ask, Community Care must give you (at no cost to you) any records, reports, and other information we have that is relevant to your Fair Hearing request.

When will the Fair Hearing be decided?

If you ask for a Fair Hearing it should be decided within 90 days from when the Pennsylvania Department of Human Services gets your request. A letter will be sent to you after the decision is made. This letter will tell you the reason(s) for the decision. It will tell you what to do if you do not agree with the decision.

These are your Member Complaint rights and responsibilities. Call us if you want us to explain them to you.

If you have any questions, you can call: