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Your Rights as a Member
Your
Rights | You
Can File a Complaint or Grievance
You Can
Accept or Refuse Treatment | Confidentiality
and Disclosure of Medical Information
You Can File a Complaint or Grievance
What is the Difference Between a Complaint and
a Grievance?
- You file a complaint when you have questions or concerns
related to your benefits or services, provider status,
exclusions or other issues related to coverage.
- You file a grievance when you disagree with the decision
of a denial of a health care service that was made by
Keystone, based primarily on medical necessity or appropriateness.
More information
available.
The Complaint Process
Informal Member Complaint Process
The Caring Foundation and Keystone will make every attempt
to answer any questions or resolve any concerns you have
related to your benefits or services.
If you have a concern:
- Call the Caring Foundation at 1-800-464-5437; or
- Write to the Supervisor of Member Services, Caring
Foundation, P.O. Box 13449, Philadelphia, PA, 19101-3449.
Most concerns are resolved informally at this stage.
If the Caring Foundation cannot immediately resolve your
concern, we will investigate it and respond to you within
30 days.
If you are not satisfied with the response to your concern
from the Caring Foundation, you have the right to file
a formal complaint within 60 days, through
the formal member complaint process described below.
Formal Member Complaint Process
You may file a formal complaint regarding an unresolved
dispute or objection regarding your coverage, including
contract exclusions and non-covered benefits, participating
or non-participating health care provider status, or the
operations or management policies of Keystone.
The complaint process consists of two internal levels
of review by Keystone, and one external level of review
by the Pennsylvania Department of Health or the Pennsylvania
Insurance Department.
Remember that no legal action can be taken until all
of the complaint procedures below have been followed.
Internal First Level Complaint
You may file a formal complaint within 60 days from either
your receipt of the original Explanation of Benefits (EOB)
or denial letter from Keystone, or from completion of
the informal complaint process described above.
To file a first level complaint:
- Call the Caring Foundation at 1-800-464-5437; or
- Write to Keystone Member Services, PO Box 8339, Philadelphia,
PA 19101-8339.
Keystone’s review of your complaint will be completed
within 30 days from the date of receipt
of your complaint by Keystone. Keystone will send you
a decision in writing no later than five business
days after reaching a decision.
If you are not satisfied with the decision on your first
level complaint, you may file a second level complaint
with Keystone, within 60 days from receipt
of the first level decision letter.
Internal Second Level Complaint
To file a second level complaint:
- Write or call the Member Appeals Unit at P.O. Box
41820, Philadelphia, PA 19101-1820, 1-888-671-5276 or
fax 1-888-671-5274 within 60 days from your receipt
of the first level decision letter from Keystone.
Keystone will contact you to arrange the second level
complaint committee meeting, which will meet and render
a decision within 45 days from the date
of Keystone’s receipt of your second level complaint.
The second level complaint committee is composed of at
least three members who have had no previous involvement
with the case. The second level complaint committee members
will include Keystone staff, with one-third of the committee
being enrollees or other persons who are not employed
by Keystone.
You have the right to present your second level complaint
to the committee in person, through a representative,
or via conference call.
The second level complaint committee meetings are a forum
where members are allowed to present their issues in an
informal setting that is not open to the public. Two other
persons may accompany you unless you receive prior approval
from Keystone for additional assistance due to special
circumstances. Members of the press may attend only in
their personal capacity as a member’s representative.
Members may not audio- or video-tape the proceedings.
Keystone will send you a written notice of the decision
within five business days of the decision by the second
level complaint committee. The decision is final unless
you choose to appeal to the Pennsylvania Insurance Department
or Department of Health within 15 days after your receipt
of the second level decision notice from Keystone.
External Complaint Review
If you wish to appeal the second level complaint decision,
you may contact the Pennsylvania Insurance Department
or Pennsylvania Department of Health within 15 days after
your receipt of the second level decision notice from
Keystone, as follows:
Pennsylvania Insurance Department
Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, PA 17120
1-877-881-6388
Bureau of Managed Care
Pennsylvania Department of Health
Attn: Complaint Appeals
P.O. Box 90
Harrisburg, PA 17108-0080
1-888-466-2787
Your complaint appeal should include your name, address,
telephone number, the name of Keystone Health Plan East
as your managed care plan, your Keystone ID number, and
a brief description of the issue being appealed. Also
include a copy of your original complaint to Keystone
and copies of any correspondence and decision letters
from Keystone.
Please note that these procedures may change due to changes
in the applicable state and federal laws and regulations.
Member Grievance Process for Decisions Based
on Medical Necessity
- Members may file a grievance of a decision made by
Keystone regarding a determination of coverage that
was based primarily on medical necessity or appropriateness.
- The grievance process consists of two internal grievance
reviews by Keystone and an external review through an
external utilization review agency assigned by the Pennsylvania
Department of Health.
- Remember, no legal action can be taken until all of
the grievance procedures have been followed.
Internal First Level Grievance
You, or your provider acting on your behalf, with your
written consent, may file a grievance within 60
days of the original Explanation of Benefits
(EOB) or denial letter from Keystone, by:
- Calling as directed in the original notice from Keystone;
- Calling the Caring Foundation at 1-800-464-5437; or
- Writing to the Patient Care Management Department,
P.O. Box 7890, Philadelphia, PA 19101.
When filing the first level grievance, you (or your provider)
must include all necessary supporting information.
The grievance will be forwarded to the first level grievance
committee. The first level grievance will be reviewed
by one or more persons selected by Keystone who did not
previously participate in the decision to deny payment
for a health care service and shall include a licensed
physician, or, where appropriate, a licensed psychologist,
in the same or similar specialty that typically manages
or consults on the health care service.
The first level grievance committee will complete its
review within 30 days from the date of
receipt of your first level grievance request by Keystone.
Keystone will then send you and your provider written
notice of the decision within five business days
of the decision.
The notice will specify the reasons and clinical rationale
for the decision and the procedure for appeal. If at that
time, you, or your provider on your behalf and with your
written consent, wish to appeal the decision of the first
level grievance committee, you may appeal to the second
level grievance committee within 60 days
of receipt of the notice of denial.
Expedited Grievance When a Serious Medical Condition
Requires a 48–Hour Review
If your case involves a serious medical condition which
you believe would jeopardize your life, health or ability
to regain maximum function while awaiting a standard internal
first or second level grievance committee review, you,
or your provider acting on your behalf and with your written
consent, can ask to have your case reviewed by Keystone
in a quicker manner. This is called an expedited grievance.
You may request an expedited grievance by:
- Calling as directed on the original notice from Keystone;
or
- Calling the Caring Foundation at 1-800-464-5437.
Keystone will arrange to have the grievance reviewed
by a Keystone medical director who was not involved previously
with the case.
This review will be completed promptly, based on your
health condition, but in no more than 48 hours
after receipt of your grievance request by Keystone.
If you are not satisfied with the expedited decision
from Keystone, you may file an internal second level grievance
to the second level grievance committee, as described
below.
Internal Second Level Grievance
You, or your provider acting on your behalf and with
your written consent, may file a second level grievance
on your behalf by:
- Writing or calling the Member Appeals Unit at P.O.
Box 41820, Philadelphia, PA 19101-1820, 1-888-671-5276
or fax 1-888-671-5274 within 60 days
after your receipt of the first level grievance decision
letter from Keystone.
The second level grievance committee, will meet and render
a decision promptly, based on your health condition, but
no later than 45 days after receipt of
your grievance request by Keystone. The second level grievance
will be reviewed by three or more persons selected by
Keystone who did not participate previously in the decision
to deny payment for a health care service. The second
level grievance committee shall include a licensed physician,
or, where appropriate, a licensed psychologist, in the
same or similar specialty that typically manages or consults
on the health care or service involved.
If you are appealing to the second level grievance committee,
you may designate a representative to participate on your
behalf. You have the right to present your second level
grievance in person, through a representative, or via
conference call.
The second level grievance committee meetings are a forum
where members are allowed time to present their issues
in an informal setting that is not open to the public.
You may be accompanied by a maximum of two other persons
unless you receive prior approval from Keystone for additional
assistance due to special circumstances. Members of the
press may attend only in their personal capacity as a
member’s representative. Members may not audio- or video-tape
the proceedings.
Keystone will send you and your provider written notice
of the decision within five business days
after the decision by the second level grievance committee.
The decision is final unless you, or your provider acting
on your behalf and with your written consent, choose to
file an external grievance within 15 days
of receipt of the second level decision by Keystone.
External Grievance
If you disagree with the second level grievance committee
decision, you may request an external grievance by an
independent utilization review agency assigned by the
Pennsylvania Department of Health. To request an external
grievance:
- Write to the Patient Care Management Department, P.O.
Box 7890, Philadelphia, PA 19101 within 15 days
of receipt of the second level decision letter from
Keystone.
- If your health care provider files a grievance on
your behalf, Keystone will verify with you that the
provider is acting on your behalf, with your consent.
- You will not be required to pay any of the costs associated
with the external review except for a $25 filing fee,
payable to Keystone, that should be forwarded to the
patient care management department at the above address.
Keystone will contact the Pennsylvania Department of
Health to request assignment of a certified utilization
review agency to your grievance. Keystone will notify
you of the name, address and telephone number of the external
agency assigned by the Department of Health to your grievance
within two business days of the assignment
by the Department.
You, your provider (if authorized to act on your behalf)
and Keystone have two business days to
notify the Department of Health, if there is an objection
to the assignment of the external review agency on the
basis of conflict of interest.
The external review agency will send you, your provider
(if authorized to act on your behalf) and Keystone a written
decision within 60 days of the date when
you or your provider filed your request for an external
review. Upon receiving the decision from the external
review agency, Keystone will authorize payment for services
or pay claims if the decision of the external review agency
is that the services were medically necessary. The external
grievance decision may be appealed to a court of competent
jurisdiction within 60 days of the decision
by the external agency.
Please note that these procedures may change due to changes
in the applicable state and federal laws and regulations.
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