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