The following is a description of the process.
Grievance - An expression of member/provider dissatisfaction about any matter other than an action, as action is defined. Examples of grievances include dissatisfaction with quality of care, quality of service, rudeness of a provider or a network employee and network administration practices. Administrative grievances are generally those relating to dissatisfaction with the
delivery of administrative services, coverage issues, and access to care issues.
To file a grievance on behalf of a member, call Member Services at 1-888-756-0004. Should the member, or provider filing on behalf of a member, need assistance, AmeriHealth Caritas Louisiana staff is trained to assist the member or provider including documenting the grievance. The provider can also, with the members consent, write to us at:
AmeriHealth Caritas Louisiana
10000 Perkins Rowe, Ste. 400
Baton Rouge, LA 70810
An acknowledgement letter to the member (with a copy to the provider filing on behalf of the member) will be mailed within 1 business day of when our receipt of the receive your grievance.
Providers may follow the processes below by filing on behalf of the member and with the member's written consent. AmeriHealth Caritas Louisiana recommends that the written consent contain the following elements:
The consent document giving the health care provider authority to pursue a Grievance on behalf of a member should include each of the following elements:
- The name and address of the member, the member's date of birth, and the
- Member's identification number.
- If the member is a minor, or is legally incompetent, the name, address and relationship to the member of the person who signs the consent for the member.
- The name, address and identification number of the health care provider to whom the
member is providing the consent.
- The name and address of the plan to which the Grievance will be submitted
- An explanation of the specific service for which coverage was provided or denied to the member to which the consent will apply.
- The following statements:
- The consent of the member or the member's legal representative is automatically rescinded if the health care provider fails to file a grievance, or fails to continue to prosecute the grievance through the second level review process.
- The member or the member's legal representative, if the member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his/her satisfaction. The member, or the member's legal representative understands the information in the member's consent form.
- The consent document must also have the dated signature of the member, or the member's legal representative if the member is a minor or is legally incompetent. A sample member consent form can be found in Appendix 21 (PDF).
Members, or providers filing on their behalf, may file a grievance within thirty (30) days from the date of the incident complained of or the date the member receives written notice of the decision of the grievance.
The Grievance Review Committee performs the review. The committee is composed of one or more employees of AmeriHealth Caritas Louisiana who were not involved in any previous level of review or decision making on the issue that is the subject of the grievance. For grievances involving clinical issues, the Grievance Review Committee shall include a licensed physician. The physician on the committee decides the grievance. The committee receives a written report from a licensed physician or other appropriate provider in the same or similar specialty that typically manages or consults on the service/item in question.
The Grievance Review Committee completes its review of the grievance as expeditiously as the member's health condition requires, but no more than ninety (90) days from receipt of the grievance, which may be extended by fourteen (14) days at the request of the member if the complaint involves any of the issues listed in items (a)-(e) in this document‘s definition of the
AmeriHealth Caritas Louisiana sends a written notice of the grievance decision to the member and other appropriate parties within five (5) business days from the decision, but not later than ninety (90) days from receipt of the grievance by AmeriHealth Caritas Louisiana, unless a fourteen (14) day extension was granted, in which case the member or member representative may file a request for a fair hearing within thirty (30) days from the mail date on the written notice of the grievance decision if the grievance disputes the failure to provide a service/item, or to decide an appeal within specified time frames, or disputes a denial made for the reason that a service/item is not a covered benefit or disputes a denial of payment after a service(s) has been delivered because the service/item provided is not a covered benefit for the member. Fair hearing procedures are outlined further in this section.