Appeals and Grievances

We want you to be happy with the health care and service you get. Let us know if a doctor, hospital, or we do something that you’re unhappy about. We will try to fix any problems over the phone. If you do not like something or we cannot fix your problem, you can file a grievance or an appeal.

How to File a Grievance or Appeal
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Call Member Services if you need help or have questions about how to file a grievance or appeal. You cannot be punished for filing a grievance or appeal. You can have someone file an appeal for you or speak for you. If you want to have someone file an appeal or speak for you, we will need to have your approval in writing.

You or your representative can get help with a grievance or appeal by asking for a Member Advocate. A Member Advocate can help you:

  • File your grievance or appeal.
  • Help you through the grievance or appeal process.
  • Answer your questions about the grievance or appeal process.
  • Help you get additional information from your doctor to help with your grievance or appeal.
Grievances

A grievance is a statement of unhappiness, like a complaint, and can either be filed in writing or verbally over the phone. A grievance can be about any service you received from a doctor or us.

Note: Do not file a grievance if you have received a denial of benefits for health care service. Those matters are handled as appeals. Find information about how to file an appeal below.

Some examples of a grievance are:

  • If a provider or our employee was rude to you.
  • If you feel a provider or we did not respect your rights as a member of our plan.
  • If you have a problem with the quality of care or service you have received.
  • If you have trouble finding or getting services from a provider.

You can send or attach any papers to the grievance form that will help us look into the problem. You can find the grievance form on our website.

You can contact us at:

Highmark Health Options Appeals and Grievances
P.O. Box 106004
Pittsburgh, PA 15230
Phone: 1-844-325-6251

How do you file a grievance?

A grievance may be filed at any time. You can talk to us or write to us.

What happens after you file a grievance?

After you file a grievance, we will send you a letter within 5 business days. This letter will tell you that we have received your grievance. It will include information about the grievance process and your rights, including your right to:

  • Appoint a representative to act on your behalf.
  • Submit additional information.
  • Review or request a copy of all documentation regarding the grievance upon request, free of charge.

Your grievance will be reviewed by one of our staff members who has not been involved with your grievance but knows the most about your issue. A decision will be made within 30 calendar days after we receive your grievance. After a decision is made, a decision letter will be mailed to you. This letter will tell you the reason(s) for the decision.

What if you need help during the grievance process?

If you need help filing a grievance, understanding the grievance process, or getting information for us to review, call a Member Advocate at 1-855-430-9852 or Member Services.

Appeals

If you are informed of a denial of benefits, you can file an appeal. An appeal gives you a chance to say why you disagree with a denial of benefits.

A denial of benefits means:

  • You have been denied a service you asked for.
  • The service you asked for has been limited.

When you receive a letter telling you that your request for services is denied, you have the right to ask for an appeal. The appeal process is a review of the decision to deny or limit the service you asked for. This includes:

  • Type or level of service.
  • Reduction, suspension, or termination of a service.
  • Denial in whole or in part of payment for a service.
  • Failure to provide a service in a timely manner.

You can win or lose the appeal. If you lose the appeal, you can appeal a second time by asking for a State Fair Hearing. 

If you are denied benefits, you or your representative may ask for a copy of the rules used to make the decision by calling 1-844-325-6251 or TTY 711 or 1-800-232-5460 or by writing to:

Highmark Health Options
Attn: Appeals and Grievance
P.O. Box 106004
Pittsburgh, PA 15230

Note: Highmark Health Options does not reward health care providers for delaying, limiting, or denying health care services or benefits. Our staff does not get paid from Highmark Health Options or any other provider for making decisions about benefits or medically necessary services that result in less or more health care coverage and services.

Read This If You Want to File an Appeal

You or your representative, including an attorney, can ask for an appeal from Highmark Health Options if you disagree with a denial. If a representative or doctor files an appeal for you, you must give them your approval in writing. If a representative or doctor files an appeal for you, you cannot file a separate appeal on your own. You have the right to submit written comments, documents, or other information about to the appeal.

How can you file an appeal?

  • By filling out the appeal form that came with your letter and mailing it back.
  • By filling out the appeal form online.
  • By calling Member Services.

When you file your appeal, include:

  • Your name and member ID number (found on your ID card).
  • Your phone number and address.
  • What you are appealing.
  • Why you are appealing.
  • What you want as a result of your appeal.

Use this address. Include any information that will help us review your appeal:

Highmark Health Options
Appeals and Grievances
P.O. Box 106004
Pittsburgh, PA 15230
Phone: 1-844-325-6251

When should you file an appeal?

You or your representative must file your appeal within 60 calendar days of the date of the Notice of Adverse Benefit Determination letter. This is the letter that tells you a service was denied or limited.

What can you do to continue getting services during the appeal process?

You may ask to continue to receive services during the appeal process if:

  • You file the request for the appeal on time.
  • We are ending, suspending, or reducing services that were approved before.
  • The services were ordered by a doctor.
  • The original time period covered by the original authorization has not run out.
  • You ask to continue receiving services within 10 calendar days of us sending the Notice of Adverse Benefit Determination.

If we continue your services during the appeal process, we will cover these services until:

  • You or your representative withdraw the appeal.
  • You or your representative fail to request a State Fair Hearing and continue getting services within 10 calendar days of us sending the Notice of Adverse Benefit Determination.
  • You receive a decision from the State Fair Hearing officer that was not in your favor.

What happens after you file an appeal?

You will get a letter from us within 5 business days. This letter will tell you that we have received your appeal. It will also include information about the appeal review process. You may have someone represent you. You or your representative may submit additional information and ask to look over all documents for the appeal.

You may also request a copy of the information used to review your appeal free of charge. In addition, you or your representative have the right to give additional information in person at the time of the appeal hearing, in writing, by phone, or by fax to 1-833-841-8074.

An Appeals Committee will review your appeal and make a decision. The committee members include a representative of the State, a physician, and a representative from our Quality Department or their designee. The committee members have not been previously involved with the issue of your appeal.

You or your representative may extend the time frame for making the appeal decision for up to 14 calendar days. We may also extend the time frame for decision up to 14 calendar days if additional information is necessary and the delay is in your best interest. If we extend the time frame, we will call you and send you a written notice with the reason for the delay.

A decision letter will be mailed to you within 30 calendar days of the date you filed your appeal or within 2 business days of the decision, whichever is sooner. This letter will tell you the reason for our decision and your further appeal rights. This includes your right to ask for a State Fair Hearing.

What if you need help during your appeal?

If you need help filing an appeal, figuring out the appeal process, or getting information for us to review, call a Member Advocate or Member Services. If you need a translator, we will arrange one for you at no cost.

What if you do not agree with our appeal decision?

If you do not agree with our decision, you or your representative may ask for a State Fair Hearing.

How can you get help to understand our appeal decision?

You have the right to receive help with understanding this decision. You can:

  • Speak with a Highmark Health Options Member Advocate or Member Services Representative by calling 1-844-325-6251 (TTY 711 or 1-800-232-5460).
  • Call one of the following community organizations for free legal assistance:

Community Legal Aid Society Inc.
New Castle County: 1-302-575-0660
Kent County: 1-302-674-8500
Sussex County: 1-302-856-0038

Delaware Volunteer Legal Services
New Castle County: 1-302-478-8850 (toll-free)
Kent and Sussex County: 1-888-225-0582

Expedited (Fast) Appeals

What should you do if you need a decision in less than 30 days?

If you think that waiting up to 30 calendar days for an appeal decision could cause you serious health concerns, you or your representative may ask for an expedited (fast) appeal.

You, your representative, or doctor can ask for a fast appeal by talking or writing to us. If we agree that you should get an appeal decision faster, you will receive a decision within 72 hours. If we do not agree, we will tell you by phone within 2 calendar days of getting your request that your appeal will follow the standard appeal process. You will also receive a letter stating your appeal will be processed as a standard appeal. It will also include information about the appeal review process. 

You or your representative may submit additional information and may ask to look over all documents for the appeal. You may also request a copy of the information used to review your appeal free of charge. You or your representative have the right to give additional information in person at the time of the appeal hearing, in writing, by phone, or by fax:

Highmark Health Options
Appeals and Grievances
P.O. Box 106004
Pittsburgh, PA 15230
Phone: 1-855-325-6251
Fax: 1-833-841-8074

What happens after you file a fast appeal?

You, your representative, or doctor may:

  • Submit additional information.
  • Look over all papers regarding the appeal upon request free of charge.

An Appeal Committee will review your appeal and make a decision. The Appeal Committee members include a representative of the State, a physician, and a representative from our Quality Department or their designee. The committee members have not been involved with the issue of your appeal.

You will be verbally notified of a decision within 72 hours of the date you filed your fast appeal. The letter will tell you the reason for the decision and your further appeal rights. This includes the right to ask for a State Fair Hearing.

 

State Fair Hearing

A State Fair Hearing is an appeal process given by the State of Delaware. You may ask for a State Fair Hearing after receiving notice of the appeal decision.

Why do you get a State Fair Hearing?

You or your representative may ask for a State Fair Hearing if:

  • We have denied, suspended, terminated, or reduced a service.
  • We have delayed service.
  • We have failed to give you timely service.

You can ask for a State Fair Hearing by contacting:

DMMA Fair Hearing Officer
1901 North DuPont Highway
P.O. Box 906
New Castle, DE 19720
Phone: 1-302-255-9500 or toll free at 1-800-372-2022

When should you file a State Fair Hearing?

If you or your representative are not happy with an appeal decision, you may ask for a State Fair Hearing within 90 calendar days of the date on the Appeal Notice of Resolution.

What happens after you file a State Fair Hearing?

You or your representative will get a letter from the State Fair Hearing officer that will tell you the date, time, and place of the hearing. The hearing can be held in person or by phone. The letter will also tell you what you need to know to get ready for the hearing.

You or your representative may review all papers regarding the State Fair Hearing. We will also have a representative at a State Fair Hearing.

The DMMA State Fair Hearing officer will send you a letter with their decision within 90 calendar days of the date of your request. If you request a fast State Fair Hearing, they will send you a letter within 3 business days of the date of the hearing.

How do you continue getting services during the State Fair Hearing process?

If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting services if:

  • You file a State Fair Hearing within 10 calendar days of the date on the Appeal Notice of Resolution.
  • You file for a State Fair Hearing on or before the effective date of the proposed action.
  • The services were ordered by a doctor.
  • The original time period covered by the original authorization has not run out.

If we continue your services during the State Fair Hearing process, we will continue to cover these services until:

  • You get the State Fair Hearing decision.
  • You or your representative withdraw the State Fair Hearing.
  • The time period or service limits you were previously authorized for has been met.

It is important to know that you may have to pay for the services you received while your State Fair Hearing was being decided if the final decision is not in your favor. If the decision was in your favor, Highmark Health Options will arrange for these services right away.

What if you do not like the State Fair Hearing decision?

If you or your representative are unhappy with the State Fair Hearing decision, you can ask for a judicial review in Superior Court. To do this, you must file with the clerk (prothonotary) of the Superior Court within 30 calendar days of the date of the State Fair Hearing decision.