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Grievance and Appeals
Provider Complaint/Grievance and Appeal Process
Claim Complaints must follow the Dispute process and then the Complaint Process below. Medical necessity and authorization denial complaints are handled in the Appeal process below. Please note that claim payments are not appealable. These must be handled via the Claim Dispute and Complaint process. Claim Disputes may be mailed to:
Ambetter from PA Health & Wellness
Attn: Claim Disputes
PO Box 5000
Farmington, MO 63640-5000
A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Ambetter’s policies, procedure, or any aspect of Ambetter’s functions. Ambetter logs and tracks all complaints/grievances whether received verbally or in writing. A provider has thirty (30) calendar days from the date of the incident, such as the original Explanation of Payment date, to file a complaint/grievance. After a complete review of the complaint/grievance, Ambetter shall provide a written notice to the provider within thirty (30) calendar days from the received date of Ambetter’s decision. If the complaint/grievance is related to claims payment, the provider must follow the process for claim reconsideration or claim dispute as noted in the Claims section of this Provider Manual prior to filing a Complaint.
Authorization and Coverage Complaints
Authorization and Coverage Complaints must follow the Appeal process below.
An Appeal is the mechanism which allows providers the right to appeal actions of Ambetter such as a prior authorization denial, or if the provider is aggrieved by any rule, policy or procedure or decision made by Ambetter. A provider has thirty (30) calendar days from Ambetter’s notice of action to file the appeal. Ambetter shall acknowledge receipt of each appeal within ten (10) business days after receiving an appeal. Ambetter shall resolve each appeal and provide written notice of the appeal resolution, as expeditiously as the member’s health condition requires, but shall not exceed thirty (30) calendar days from the date Ambetter receives the appeal. Ambetter may extend the timeframe for resolution of the appeal up to fourteen (14) calendar days if the member requests the extension or Ambetter demonstrates that there is need for additional information and how the delay is in the member’s best interest. For any extension not requested by the member, Ambetter shall provide written notice to the member for the delay.
Expedited appeals may be filed with Ambetter if the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding seventy-two (72) hours from the initial receipt of the appeal. Ambetter may extend this timeframe by up to an additional fourteen (14) calendar days if the member requests the extension or if Ambetter provides evidence satisfactory evidence that a delay in rendering the decision is in the member’s best interest.
Providers may also invoke any remedies as determined in the Participating Provider Agreement.
Member Complaint/Grievance and Appeal Process
To ensure that Ambetter member’s rights are protected, all Ambetter members are entitled to a Complaint/Grievance and Appeals process. The procedures for filing a Complaint/Grievance or Appeal are outlined in the Ambetter member’s Evidence of Coverage. Additionally, information regarding the Complaint/Grievance and Appeal process can be found on our website at Ambetter.PAhealthwellness.com or by calling Ambetter at 1-833-510-4727.
The member may also access the member complaint form online [link to PDF].
If a member is displeased with any aspect of services rendered:
- The member should contact our Member Services department at 1-833-510-4727. The Member Services representative will assist the member.
- If the member continues to be dissatisfied, they may file a formal complaint/grievance. Again, our Member Services department is available to assist with this process. Information regarding this process can be found at Ambetter.PAhealthwellness.com.
- Depending on the nature of the complaint/grievance, the member will be offered the right to appeal our decision. At the conclusion of this formalized process, the member will receive written confirmation of the determination. Ambetter will complete the appeal process in the timeframes as specified in rules and regulation.
- The member has the right to appeal to an external independent review organization.
- A member may designate in writing to Ambetter that a provider is acting on behalf of the member regarding the complaint/grievance and appeal process.
The mailing address for non-claim related Member and Provider Complaints/Grievances and Appeals is:
Ambetter from PA Health & Wellness
300 Corporate Center Drive
Camp Hill, PA 17011