Understanding the complaint and grievance process

UPMC for Kids believes it is important that you understand the complaint and grievance process. If you have questions, you may want to talk to a Member Services representative who can explain the process and answer your questions.

A Member Services representative may be able to resolve your concerns over the telephone. However, if the representative is unable to resolve your concerns, he or she can assist you with filing a complaint or a grievance.

Definitions:

• A grievance is a request that UPMC for Kids reconsider a decision concerning the medical necessity and appropriateness of a health care service.
  
• A complaint is a request that UPMC for Kids resolve a dispute or problem regarding a provider, or coverage, operations, or management policies of UPMC for Kids. Complaints can involve quality of care, quality of service, benefits exclusion, claim denial, and other similar matters. 

Please note: Your benefit plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered.