ENROLLEE GRIEVANCES a. The CONTRACTOR shall address all clinical concerns of the Enrollee as related to the clinical services provided to the Enrollee pursuant to this contract. CONTRACTOR shall refer any unresolved concerns or requests for LME/PIHP services or provider change to the LME/PIHP. The CONTRACTOR shall have in place a Complaint and Grievance Process that is documented in written policy or procedures, and shall ensure that said process is accessible to all Enrollees and that said process operates in a fair and impartial fashion.
b. The LME/PIHP may receive complaints directly, which involve the CONTRACTOR. If a complaint is received by the LME/PIHP, State rules/regulations regarding the investigation and/or mediation of complaints will be followed. Based on the nature of the complaint, the LME/PIHP may choose to investigate the complaint, as authorized by Controlling Authority, in order to determine its validity. CONTRACTOR will be required to cooperate fully with all investigative requests as required by Controlling Authority.
c. The LME/PIHP will maintain documentation on all follow up and findings of any complaint investigation. The CONTRACTOR will be provided a written summary of the LME/PIHP’s findings.
d. During an investigation, if any issues are cited as out of compliance with this Contract or Controlling Authority, the CONTRACTOR may be required to document and implement a plan of correction as required by Controlling Authority. The CONTRACTOR will maintain a system to receive and respond timely to complaints received regarding the CONTRACTOR. The CONTRACTOR will maintain documentation on the complaint to include, at a minimum, date received, points of complaint, resolution/follow up provided, and date complaint resolved.
ENROLLEE GRIEVANCES. The LME/PIHP’s Anonymous Concern and Complaint line must be published and made available to Enrollees and family members.
ENROLLEE GRIEVANCES. Physician Group agrees to cooperate with Health Plan in resolving Enrollee grievances related to Physician Group or Group Providers. Health Plan will bring to the Physician Group’s attention all Enrollee grievances involving Group Providers, and Physician Group will investigate such grievances and use its best efforts to resolve them in a fair and equitable manner. Physician Group agrees to notify Health Plan promptly of any action taken or proposed with respect to the resolution of such grievances and the avoidance of similar grievances in the future. Physician Group’s failure to resolve a grievance through its established procedures could result in the application of Health Plan’s grievance procedures or procedures required by HCFA.
ENROLLEE GRIEVANCES. TBH shall have primary and final responsibility for administering Enrollee grievance procedures. Provider shall be given notice of and the right to participate in any Enrollee grievance procedure.
ENROLLEE GRIEVANCES. THP or the Payor, as determined by the terms of the Master Agreement, shall have primary and final responsibility for administering Enrollee grievance procedures.
ENROLLEE GRIEVANCES. The Contractor shall submit supplemented call scripts to the Department for review:
ENROLLEE GRIEVANCES. The PCC shall assist in Grievance resolution procedures as follows:
A. If an Enrollee has a Grievance related to the PCC, the PCC shall work cooperatively with the Enrollee and EOHHS to resolve the Grievance.
B. If the Enrollee wishes to file a Grievance, the PCC shall instruct the Enrollee to contact the MassHealth Customer Service Center.
