Advanced Grievances

A Grievance is:

Abbreviations are ok to be included in Grievance documentation, as long as the ICR captures all the details of the calls.

Maria called expressing dissatisfaction with agent Brenda Rodriguez who enrolled her in the plan. Maria states that she asked if CarePlus was affiliated with Memorial Hospitals and if care at those hospitals was covered.  She was told yes, but the sales agent did not advise her that we services are only covered at Memorial Pembroke Pines and not Memorial Hospital West, so Maria assumed all memorial hospital locations were in network.  Which type of Grievance would this be?

Member calls stating the following "I've been calling my primary doctor's office for over a week. I keep getting the answering service, but no one calls me back!  I need to see my doctor."  Which type of Grievance is this?

Member called expressing dissatisfaction with her PCP, Alfred Soto. She states that every time she requests to see a specialist, Dr Soto always tells her that he can provide that service to the member at his office and does not give her the referral she wants.

“So in order for me to just start my appeal I have to send you a letter?! That’s so stupid. You should just give me what I want. You guys denied my claim for Quest Diagnostics and now I have to go to the post office to just make sure you can do your jobs?!”  For which Grievance category would you document this call?

Lena expresses dissatisfaction that she has to send a request in writing to disenroll from CarePlus. Member does not think that it is fair that we can sign her up "just that fast" but we cannot process her disenrollment request as fast. Member also doesn't think it's fair that she is subjected to a lock in period. Which type of Grievance is this?

During a call, Fernand, expresses dissatisfaction with Greenberg Dental. He mentions that he was fitted for dentures at the 620 Commerce Center DR#155, Jacksonville, FL office. The member states he keeps getting an invoice letter stating to pay $207 for supplies used but doesn’t know why he would be responsible for supplies used as part of his fitting.  Which type of Grievance would you document?

What STC will you document if the member you are speaking with says, “Every time I call CarePlus I hear the same old music. Your hold music is so annoying.  It makes my ears bleed…uuugh!”

Member expressed dissatisfaction with CarePlus Health Plans because he was told in the hospital that he needs to drink Boost or Ensure because it helps him with his condition and CarePlus doesn't cover it.  You would log this as which type of Grievance?

Which of the following would NOT be classified as a Quality of Care grievance?

Larry calls in to report that his PCP's office keeps on sending him DMEs that he does not need.  What grievance category would you document this as?

Which of the following is unable to submit a valid grievance?

What is the resolution timeframe for a Part C expedited grievance?

An ICR can expedite a grievance if the plan extends the timeframe to make a determination .