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If a member files a grievance against a provider in reference to the quality of care or service provided, the
Plan will fax and mail a request to the provider for response.
Provider Responsibility
The provider is given 10 business days to respond and submit medical records for review. If a provider has not responded within 10 business days, a second fax and certified letter is sent giving an additional five business days.
Continued failure to respond may result in the provider’s panel being closed to new patients and/or will be
interpreted as an indication that the provider does not disagree with the member’s issue. The case is then
forwarded to the Quality Improvement department for further investigation.
If the provider does respond, the case is referred to a Plan nurse who reviews the medical records to
determine if a possible quality issue exists. If the nurse feels a possible quality issue does exist, the case is
referred to a Plan medical director for review. If he/she determines a quality issue exists, the case is referred to the Quality Improvement department for further investigation. If no quality issue is identified, the case is
entered into the Plan’s database for tracking and trending purposes.
14-Day Extension
Each of the appeal or grievance determination periods noted above may be extended by as many as 14
calendar days, if the member requests an extension or if the Plan justifies a need for additional information and
documents how the extension is in the interest of the member. If an extension is not requested by the member,the Plan will provide the member with written notice of the reason for the delay.
Plan will fax and mail a request to the provider for response.
Provider Responsibility
The provider is given 10 business days to respond and submit medical records for review. If a provider has not responded within 10 business days, a second fax and certified letter is sent giving an additional five business days.
Continued failure to respond may result in the provider’s panel being closed to new patients and/or will be
interpreted as an indication that the provider does not disagree with the member’s issue. The case is then
forwarded to the Quality Improvement department for further investigation.
If the provider does respond, the case is referred to a Plan nurse who reviews the medical records to
determine if a possible quality issue exists. If the nurse feels a possible quality issue does exist, the case is
referred to a Plan medical director for review. If he/she determines a quality issue exists, the case is referred to the Quality Improvement department for further investigation. If no quality issue is identified, the case is
entered into the Plan’s database for tracking and trending purposes.
14-Day Extension
Each of the appeal or grievance determination periods noted above may be extended by as many as 14
calendar days, if the member requests an extension or if the Plan justifies a need for additional information and
documents how the extension is in the interest of the member. If an extension is not requested by the member,the Plan will provide the member with written notice of the reason for the delay.
Posted in: Wellcare insurance appeal
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