What is a complaint?

A complaint is a written or verbal expression of dissatisfaction

  • It can be made by a member, a member’s representative or a provider on behalf of a member
  • It may be about HPSM, a service, a provider and/or a facility

A Complaint can be either a Grievance or an Appeal

An Appeal is a request for review of services that were denied, limited or taken away, such as:

  • a denied request for services (i.e. prior authorization)
  • a denied request for payment to a provider (i.e. claim)
  • a denied request for reimbursement to a member

A Grievance is an expression of dissatisfaction about services or supports such as:

  • the quality of the care that was received
  • customer service that was perceived as rude or unhelpful
  • access to care and/or the timeliness of care
  • billing-related issues such as receipt of a balance bill and/or collections notice
  • other issues, such as HIPAA violations or potential instances of fraud