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 Understanding the complaint and grievance process
A Member Services representative may be able to resolve your concerns over the telephone. If that is not possible, he or she can help you file a complaint or grievance. You may file a complaint if you have a dispute or problem regarding a provider or UPMC for You’s coverage, operations, or management policies. Complaints can involve quality of care, quality of service, benefits exclusions, claim denials, and other similar matters. You may file a grievance if you want UPMC for You to reconsider a decision concerning the medical necessity and appropriateness of a health care service. The UPMC for You member handbook, Section 6, Complaints and Grievances, contains important information about the complaint and grievance process. You can find the member handbook under “Member Information” on our website at upmchealthplan.com/plan/assistance. It also explains what UPMC for You may do to resolve your concerns and what happens during each step of the complaint and grievance process. The Rights and Responsibilities document (also in the member handbook) explains your rights as a UPMC for You member. To request a paper copy of either document or to ask questions, call Member Services at 1-800-286-4242. Representatives are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m. TTY users should call 1-800-361-2629. |
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