Tips on Filing Complaints and Preparing for Appeals

When you have a disagreement with your health plan and you can't get it resolved by talking to someone, you may need to file a formal complaint or appeal. This is your chance to present your problem and have your case reviewed. Keeping good records will help you provide all the details necessary when and if you have to file an appeal. Having all the information ready to go will help make the process go smoother, and in some cases, faster.

• Read your health plan's member handbook carefully. It has a lot of important information.
• Have your Medicaid card ready when you call to make a complaint.
• Call your Member Services Department first. They might be able to answer your questions or solve your problem.
• Start your record-keeping immediately.
  • Keep a file containing any paperwork that has to do with your problem. This might include doctor's reports, lab work, and letters from your health plan.
  • Keep a log of every telephone call you make to your health plan, doctors or anyone else involved. Always ask for the person's name and their phone number or extension.
  • Always write down the date and name of the person you talked to. Take notes about your conversation.
  • Before you hang up, find out what will happen next and when. Will someone call you back? When can you expect to receive a reply or a follow-up call? Mark the date in your notes.
  • If you do not hear back from the person or place that was supposed to call you, it's time for another phone call. Call the person back and ask him/her for an update.
• Always keep copies of the written complaint or appeal that you send to your health plan. Write down the date that you mailed it.
• You should receive a letter from the health plan stating that they received your complaint/appeal.
• Write down the date you should expect to receive a final decision. You can always call your health plan to check on the status of your complaint or appeal.

Your health plan will usually give you a form to fill out when you file a written complaint or appeal. Always provide all of the information that you are asked for. If you don't, it might delay your review. You should always include the following information in your written complaint. Sometimes you might need to provide more information.

• Your name, address and telephone number.
• Your Medicaid ID number.
• Your doctor's name.
• Description of the service or procedure that you wish covered.
• Information saying why the service should be covered.
• Recommendations and referrals from your doctor about why the treatment or procedure should be covered.

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