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