- Problems with the quality of the medical care the member receives, including the quality of care during a hospital stay
- The member believes someone did not respect their right to privacy or shared information that should be confidential
- The member feels that he or she is being encouraged to leave (disenroll from) a Peoples Health plan
- Problems with the services the member receives from member services
- Problems with how long the member has to spend waiting on the phone, in a waiting room, in a network pharmacy, or in an exam room
- Problems with getting appointments when the member needs them or having to wait a long time for an appointment
- Disrespectful or rude behavior by doctors, nurses, receptionists, network pharmacists or other staff
- Lack of cleanliness or the condition of a doctor’s office, clinic, network pharmacy or hospital
- The member disagrees with our decision not to expedite a request for an expedited coverage determination, organization determination, redetermination or reconsideration
- The member believes our notices and other written materials are difficult to understand
- Failure of Peoples Health to give the member a decision within the required time frame for a coverage decision or an appeal
- Failure of Peoples Health to provide the member with coverage or reimbursement for medical services or drugs, in accordance with the review of a coverage decision and within the required time frame
- Failure of Peoples Health to forward the member’s case to the independent review entity if we do not provide a decision within the required time frame
- Failure of Peoples Health to provide required notices
If a member has one of these types of problems, the member (or the member’s appointed representative) can file a grievance. In certain cases, the member has the right to ask for an “expedited grievance,” meaning the grievance must be responded to within 24 hours. We discuss expedited grievances in more detail in each plan’s Evidence of Coverage.