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PFFS Terms & Conditions

Complaint and Grievance Process for Commercial Members

If members have questions or concerns with UPMC Health Plan, they may call Member Services at 1-888-876-2756. For behavioral health service inquiries or concerns, members may call UPMC Health Plan Behavioral Health Services' Member Services at 1-888-251-0083. Member comments are important to us as we continually strive to improve the quality of care and service we provide.

When a member calls Member Services, a representative will respond to his or her questions or concerns. At any point in the process, if a member is not satisfied with the response, he or she may ask to file a complaint or grievance through the Health Plan's Complaint and Grievance process.

Under the provisions of the Pennsylvania HMO Act, Act 1998-68, and the Department of Health and Insurance Department regulations, the Health Plan has established a set of formal procedures that members may use if they are in any way dissatisfied with the Health Plan or a participating provider.

The claims processing rules of the Department of Labor's Employee Retirement Income Security Act (ERISA) may also apply to any complaints or grievances that a member files.

UPMC Health Plan's Complaint and Grievance process for fully insured employer groups differs slightly from the standard Complaint and Grievance process for self-insured or administrative services only (ASO) groups. These processes, and the differences between them, are noted in the text below. Members may contact their human resources or benefits department to determine whether they are members of a fully insured group or a self-insured group.

Self-insured groups may also customize their Complaint and Grievance process. Members of a self-insured group may review their plan documents or contact their human resources or benefits department to confirm that the group follows the standard Complaint and Grievance processes outlined in the following pages.

The following is a brief overview of the Health Plan's Complaint and Grievance process.


Complaints

If a member has a dispute or objection regarding a provider or the coverage, operations, or management policies of UPMC Health Plan, the member should contact Member Services.

Complaints may involve many different issues, including, but not limited to, the quality of care or service, benefits exclusion, claim denial, or coordination of benefits.

General information about complaints

You may file a complaint over the phone with a Member Services' representative by calling 1-888-876-2756. Or, you may send a written complaint or written information to support a complaint to:

UPMC Health Plan
Complaints and Grievances
P.O. Box 2939
Pittsburgh, PA 15230-2939

Members need to file a complaint within 180 days of the date they receive a claim denial or within 180 days of the event that is prompting their complaint.

At any time during the course of the complaint process, members may choose to designate a representative to represent them in the complaint process on their behalf. Members must notify the Health Plan in writing of this designation.

The complaint process consists of a two-step internal process as well as an external appeal process, should a member remain dissatisfied with the results of the internal complaint process. The complaint process is summarized in the following chart.

The Internal Complaint Process
What When Details
Initial Level Complaint Review Process
Acknowledgment Letter Upon receipt of a member's oral or written complaint UPMC Health Plan will provide the member and the member's representative with written confirmation of receipt of the complaint.
Initial Complaint Review Process Within 30 days from receipt of a complaint The Initial Complaint Review Committee (consisting of one or more employees of UPMC Health Plan who have not been involved in a prior decision on the issue under dispute) will investigate the details of the complaint. The committee will make a decision within 30 days of receipt of a complaint.
Initial Complaint Review Committee Decision Letter Within 5 business days of the decision UPMC Health Plan will send the member and the member's representative written notification of the Initial Complaint Review Committee decision within 5 business days. The committee decision will be binding, unless the member chooses to request a Second Level Review.
Request for Second Level Review Within 60 days from receipt of the initial complaint decision letter If a member requests a Second Level Review of the Initial Complaint Review decision, the complaint will go to UPMC Health Plan's Second Level Complaint Review Committee.
Second Level Complaint Review Process
Acknowledgment Letter Upon receipt of a member's request Upon receipt of a member's request for a Second Level Review, UPMC Health Plan will provide written confirmation to the member and/or the member's representative. This letter will also advise the member and the representative that they have the right to appear before the Second Level Complaint Review Committee and that UPMC Health Plan will provide the member and representative with 15 days advance written notice of the date and time scheduled for that review.
Second Level Complaint Review Process Within 30 days from receipt of a complaint The Second Level Complaint Review Committee consists of three or more individuals who did not previously participate in the matter under review. At least one-third of the committee is made up of members who are enrolled in UPMC Health Plan but who are not employed by UPMC Health Plan or a related subsidiary or affiliate. The members of the committee have the duty to be impartial in their review of the information and decision. The member and/or the member's representative have the right, but are not required, to attend the Second Level Complaint Review Committee meeting. When arranging the meeting, UPMC Health Plan will notify the member and the representative in writing 15 days in advance of the date scheduled for the Second Level Complaint Review. UPMC Health Plan will also provide details of the review process and how the meeting will be conducted, including member rights at such meetings. If the member and the member's representative cannot appear in person at the Second Level Review, UPMC Health Plan will provide the member with the opportunity to communicate with the committee by telephone or other appropriate means. UPMC Health Plan will be as flexible as possible in facilitating the member's participation and that of the member's representative.
Second Level Complaint Review Committee Decision Letter Within 5 business days of the decision Within 5 business days of the Second Level Complaint Review Committee's decision, the committee will issue a written notification to the member and/or the member's representative.
Appeal of a Complaint Decision Within 15 days from receipt of the Second Level Review decision

A member has 15 days from the receipt of the Second Level Complaint Review decision to file an appeal. The decision letter will include all necessary information on how to do so.

This option may not apply to all self-insured groups.


All acknowledgment letters in the Complaint and Grievance process contain the following information:

  • A summary of the basis of the complaint or grievance and confirmation of its classification. The letter also contains instructions for a member and/or the member's representative, should they wish to question the classification.

  • Notification that a member may designate a representative to act on his or her behalf at any time during the complaint or grievance process.

  • Notification that a member and the member's representative may request that the Health Plan assign an employee who has not participated previously in any decisions concerning the issue under dispute to assist the member and his or her representative, at no charge, in preparing the complaint.

  • Notification that a member and the member's representative may submit additional material to the Health Plan in support of their viewpoint. A member also has the right to review information related to the complaint upon request. State regulations allow managed care plans to charge a reasonable fee for this service.

All committee decision letters in the Complaint and Grievance process contain the following information:

  • The reasons for the decision.

  • References to the specific plan provisions on which the decision is based.

  • Notification that if the Health Plan has used an internal rule, guideline, protocol, or other similar criterion in the decision-making process, the specific rule, guideline, protocol, criterion, or instructions on how to obtain the specific information indicated in the decision letter will also be provided in the committee decision letter.

  • An explanation of the process to request another level of review (second or external) if a member is not satisfied with the result of the committee decision.

  • The time frame in which to request another level of review, and the address to which the request should be sent.

  • Notification that the member is entitled to receive, upon request, reasonable access to, and copies of, all documents relevant to the review.

Grievances

A grievance is different from a complaint. A grievance is a request on the part of a member, a member's representative, or a health care provider (with written member consent) to have a managed care plan reconsider a decision solely concerning the medical necessity and appropriateness of a health care service.

A grievance may be filed regarding decisions to fully or partially deny payment for a requested health service, to approve provision of a requested health care service at a lesser level or duration than requested, or to disapprove payment for the provision of a requested service but approve payment for the provision of an alternative health care service.

General information about grievances

While it is generally preferable that members file a grievance in writing, they may call Member Services to request assistance and file a grievance orally. A member's health care provider may file a grievance on the member's behalf but must do so with the member's written consent. Please note:

  • A member's health care provider may request the member's consent (in writing) to pursue a grievance at the time of treatment or service, but not as a condition of providing that treatment or service.

  • Once a member gives a health care provider consent to file the grievance, the provider has 10 days from the receipt of the Health Plan's denial to file. The provider needs to inform the member only in the event he or she decides not to file the grievance.

  • A member's consent is automatically rescinded if the health care provider fails to file a grievance or fails to continue to prosecute the grievance through the second level of the grievance process.

  • If a member wishes to file a grievance, but has already given his or her provider written consent, the member must rescind the consent in order to proceed with the filing himself or herself.

  • A member and the member's health care provider are not permitted to file separate grievances for the same denied treatment or service.

  • UPMC Health Plan has instructed all its providers on the required format for written member consents as stipulated by managed care regulations and guidance.

As with the complaint process, the grievance process consists of a two-step internal process as well as an external grievance appeal, should a member remain dissatisfied with the results of the internal grievance process decisions. The grievance process is summarized in the following chart.

The Internal Grievance Process
What When Details
Initial Level Grievance Review Process
Acknowledgment Letter Upon receipt of a member's grievance UPMC Health Plan will provide written confirmation of receipt to the member and the member's representative, if one has been designated, and the health care provider, if the health care provider filed the grievance with written member consent.
Initial Grievance Review Process Within 30 days from receipt of a member's grievance The Initial Grievance Review Committee (consisting of one or more employees of UPMC Health Plan who did not previously participate in the decision to deny payment for the health care service under dispute) will investigate the details of the grievance. This committee will include input from qualified personnel (including a licensed physician or, where appropriate, an approved licensed psychologist) with experience in the same or a similar specialty as that of a specialist who typically manages or consults on the health care service under dispute.
Initial Grievance Review Committee Decision Letter Within 5 business days of the decision UPMC Health Plan will send written notification of the committee decision. The decision will be binding, unless the member and the member's representative or health care provider who filed the grievance choose to request a Second Level Review of the decision.
Request for Second Level Review Within 60 days from receipt of the initial grievance decision letter If the member and the member's representative or the health care provider with written member consent requests a Second Level Review of the decision of the Initial Grievance Review Committee, the grievance will go to UPMC Health Plan's Second Level Grievance Review Committee.
Second Level Grievance Review Process
Acknowledgment Letter Upon receipt of a member's request


Within 30 days from receipt of a member's grievance		 Upon receipt of the request for the Second Level Review, UPMC Health Plan will provide written confirmation to the member and the member's representative and the health care provider, if the health care provider filed the grievance with written member consent. Members will also be advised that they, their representative, and the health care provider have the right to appear before the Second Level Review Committee and that UPMC Health Plan will provide the member, his or her representative, and the health care provider with 15 days advance written notice of the date and time scheduled for that review. The Second Level Grievance Review Committee consists of three or more individuals who did not previously participate in any decision to deny payment for the health care service under dispute. This committee will review input from qualified personnel (including a licensed physician and, where appropriate, an approved licensed psychologist) with experience in the same or a similar specialty as that of a specialist who typically manages or consults on the health care service under dispute. If the licensed physician or approved licensed psychologist will not be present (either in person or by telephone conference call) at the Second Level Grievance Committee Review attended by the member and the member's representative or health care provider, UPMC Health Plan will provide the member, his or her representative, and the health care provider notice of that fact in advance of the review. The member, his or her representative, or the health care provider who has filed a grievance with written member consent shall, upon written request, receive a copy of the report from the licensed physician or approved licensed psychologist at least seven days prior to the review date. The member, his or her representative, or the health care provider have the right, but are not required, to attend the Second Level Grievance Review Committee hearing. When arranging the hearing, UPMC Health Plan will notify the member, his or her representative, or health care provider in writing at least 15 days in advance of the date scheduled for the Second Level Review. UPMC Health Plan will also provide details of how the hearing will be conducted, including the member's rights at such hearings. If the member and/or his or her representative or health care provider cannot appear in person at the Second Level Review, UPMC Health Plan will provide the member and/or his or her representative or health care provider the opportunity to communicate with the review committee by telephone or other appropriate means. The Second Level Grievance Review Committee will complete its review and shall base its decision solely upon the materials and testimony presented at the review.
Second Level Grievance Review Committee Decision Letter Within 5 business days of the decision

The Second Level Grievance Review Committee will issue written notification regarding the Second Level Grievance Review Committee's decision to the member and/or his or her representative, or the health care provider who filed the grievance with written member consent. A member who is part of a fully insured group has fifteen calendar days from the Second Level Grievance Review decision to contact the Health Plan with a request for an External Review.  Information on how to file an external grievance will also be provided in the event that the fully insured member is dissatisfied with the results of the internal grievance decision.

Members of self-insured groups may contact their human resources or benefits department for details about their group's external review process.

Expedited internal grievance process

If a member believes his or her life, health, or ability to regain maximum function are in jeopardy because of any delay that the time frame for an internal grievance might cause, or believes that UPMC Health Plan failed to provide medically necessary and appropriate covered services, the member may request an expedited review.

In such cases, the member should notify Member Services of the need for an expedited review. The member should have certification in writing from his or her physician that his or her condition would be placed in jeopardy by the delay inherent in the regular time frame of the internal grievance process. UPMC Health Plan will arrange to have the grievance reviewed by a UPMC Health Plan Medical Director within 48 hours. UPMC Health Plan will inform the member/authorized representative of the decision verbally and will send a written response within three days.

The expedited review process follows all requirements of the Second Level Grievance Review, with shortened time frames due to the expedited nature of the review.

A member who is part of a fully insured group has two business days from the receipt of the Expedited Internal Review decision to contact the Health Plan with a request for an Expedited External Review. The Certified Utilization Review Entity (CRE) that conducts the External Grievance Review has two business days to issue a decision.

Members of self insured groups may contact their human resources or benefits department for details about the availability of their group's expedited external review process.

Member Services will be able to provide members with additional information or answer questions concerning our Complaint and Grievance process.

For members of fully- insured groups, the Bureau of Managed Care of the Pennsylvania Department of Health (1-888-466-2787) and the Bureau of Consumer Services in the Pennsylvania Insurance Department (1-877-881-6388) are responsible for monitoring HMO compliance with the complaint and grievance procedures, which have been established according to state law and regulation.