Grievances

What is a Grievance?

“A grievance is a request to have a BH-MCO or utilization review entity reconsider a decision concerning the medical necessity and appropriateness of a covered service.”

That means it is what you file when you do not agree with Community Care's decision that a service that you or your provider asked for is not medically necessary. A grievance is usually about your or your provider's concerns about getting treatment approved. You can file a grievance in any of the following situations:

  1. Payment of a service has been denied, in whole or in part because service is not a medical necessity
  2. The type or level of service approved has been limited due to lack of medical necessity
  3. A previously authorized service has been reduced, suspended, or terminated due to lack of medical necessity
  4. An alternative service has been approved in place of a service denied due to medical necessity

What should I do if I have a Grievance?

If Community Care does not completely approve a service that was prescribed/requested for you, we will send you a denial letter. This letter will tell you how to file a grievance and will briefly discuss your rights as a Community Care member regarding grievances.

To file a grievance, contact Community Care.

You can designate another person, or your provider, to represent you in the grievance process if you give your consent in writing. Your written authorization must include: your name, address, your date of birth, and identification number. If your provider files a grievance for you, then you cannot file a separate grievance on your own.

There is no cost to file a grievance. Also, if a service that you are already getting has been denied, you may be able to continue getting that service until the grievance process is exhausted. 

When should I file a First Level Grievance?

You have 60 days from the date that you receive this letter to file a grievance. If you have been receiving the requested service prior to a denial, you will be able to continue the disputed services until the resolution of the grievance if you call Community Care within either 1 calendar day for inpatient services or 10 calendar days for all other services from the date on the denial letter. 

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

If you need help filing your grievance, a Community Care staff person will help you. This person can assist you during the grievance 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 grievance.

You may also have a family member, friend, or other supportive person help you file your grievance. This person can also help you if you decide you want to attend the grievance review. At any time during the grievance 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. Otherwise we can only correspond with you.

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

You do not need a lawyer to file a grievance. 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 grievances at no cost.

  • Providing sign language interpreters.
  • Providing information submitted by Community Care at the grievance 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 grievance review.

What happens after I file a Grievance?

Community Care will send you a letter to let you know we received your grievance and telling you about the Grievance process. You will be able to continue the disputed services until the resolution of the grievance if you call Community Care within either 1 calendar day for inpatient services or 10 calendar days for all other services from the date on the denial letter. You may ask Community Care for access to information relevant to your grievance. You may send us information that may help with your grievance. Ask for assistance with your grievance by calling Community Care member services for your county.

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

A committee of three or more people will review your Grievance, including a doctor or psychologist from Community Care, as well as at least one person who does not work for Community Care. No one on the committee will have been involved in the issue you filed your grievance about. The committee will make a decision about your grievance and inform you of the decision within 30 days from the date you filed it. You will receive a letter telling you the reason(s) for the decision, as well as how to ask for an External Grievance review and/or a Fair Hearing if you do not like 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 grievance will harm your health, then you, your doctor, or your psychologist can call, fax, or write to Community Care to ask that your grievance be decided faster. Grievances completed within quicker than usual timelines are known as Expedited Grievances.  

Your provider must then submit a certification within 72 hours telling us the reasons why the expedited review is needed. Otherwise, the grievance 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 Grievance review process with the exception of time frames. The committee will make a decision about your grievance and inform you of the decision within 48 hours of receiving your doctor or psychologist's certification. You will also receive a letter telling you the reason(s) for the decision. It will tell you how to ask for an Expedited External Grievance review if you do not like the decision.

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

If you are not happy with the Grievance decision, you can ask for an External Grievance review by a certified review entity (CRE) appointed by the Department of Health. You must ask for this external review within 10 days of the date you receive the Grievance decision letter. Use the same address and/or phone number that you used to file your Grievance with Community Care.  Within 5 business days from the receipt of your request, we will then send your request to the Pennsylvania Department of Health. You will be able to continue the disputed services until the resolution of the External Grievance if you call Community Care within either 1 calendar day for inpatient services or 10 calendar days for all other services from the date on the Grievance decision letter.

The Pennsylvania Department of Health will notify you of the External Grievance reviewer's name, address, and phone number. You will also be given information about the External Grievance review process. Community Care will send your grievance file to the reviewer. You may provide additional information that may help with the External Grievance review to the reviewer within 10 days of receipt of notice that your request for an External Grievance Review was filed with Community Care.

You will receive a decision letter within 60 days of the date you asked for an External Grievance Review. This letter will tell you the reason(s) for the decision and what you can do if you do not agree with the decision.

Expedited External Grievances
If you want to ask for an Expedited External Grievance (by a doctor who does not work for Community Care) review, you must contact Community Care within 2 business days from the date you get the Expedited Grievance decision letter.

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

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

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 within 120 days from the mail date on the written Grievance decision notice.

How do I ask for a Fair Hearing?

You must ask for a Fair Hearing in writing. 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

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
  • Statements 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 Grievance rights and responsibilities. Call us if you want us to explain them to you.

If you have any questions about grievances, you can call: