MHP supports our members’ right to grieve or appeal any adverse decisions or coverage issues made by MHP in a timely, fair, and consistent manner.
The Corporate Appeals Department manages the appeal process according to the member’s benefit plan and government regulations.
When members believe their needs may have not been met they, or anyone on their behalf, have the right to file a complaint or appeal regarding access, availability, and/or the provision of care, cultural insensitivity, quality and/or appropriateness of services rendered.
Members may also, at any time during the complaint, grievance, and appeal process, take their concerns to the Department of Insurance, CMS, or to the employer, as applicable. When members appeal for provider payment the provider is copied on the resolution decision to assure communication between both parties.
All members are notified of their rights to file a complaint, grievance, or appeal upon enrolling with MHP.
A grievance is a complaint of dissatisfaction by a member or authorized representative about co-payments or premiums in general, the quality of care or services provided, enrollment and disenrollment issues, treatment by a provider, or failure to respect a member’s rights. Grievances may be filed in writing, or orally then followed up in writing.
An appeal is a request to change a denial, reduction, or termination of benefits. Pertaining to Medicare Advantage members, a 'standard appeal' may be filed by either members or their physician. The appeal could include complaints concerning payment for services, denial of services that include an unpaid bill, a partially unpaid bill, non-approval, or denial of care that the member feels should still be covered, or the cessation of care that, in the member’s opinion, is still necessary.