Wednesday, July 20, 2016

Member Grievance Procedure

Per regulatory guidelines and as part of the Tufts Health Plan commitment to ensuring member satisfaction, we have established a forum for members or authorized representatives to express concerns regarding their experiences with health care providers. The member grievance procedure, allows for the documentation and review of member complaints, as follows:

1. Upon receipt of a verbal or written complaint, the grievance specialist acknowledges either verbally or in writing that the complaint was received and will be reviewed within 30 calendar days or within 24 hours if the grievance is expedited. All grievances pertaining to clinical care and/or services issues are reviewed within the Clinical Quality Improvement (CQI) department. All grievances pertaining to provider billing, along with operations and activities of the Plan are reviewed within the Appeals and Grievances (A&G) department. The CQI and A&G department can accept any information or evidence concerning the grievance orally or in writing.

2. In most instances, providers or their office managers (depending on the specific situation) are notified either verbally or in writing about the complaint and asked for input.

3. If the complaint pertains to a quality of care issue (clinical grievance), the clinical review team evaluates the information. The grievance is assigned a rating for degree of severity and preventability of the issue of concern. The provider is generally notified of the results of the review. All grievances and their respective ratings are entered into our secured quality database for tracking and trending purposes. This data becomes part of the provider’s credentialing file and is reviewed periodically.
It is the member’s responsibility to notify Tufts Health Plan Medicare Preferred of concerns about his/her health care services. It is the responsibility of all network providers to participate in our grievance review process.

Providers are expected to respond to a request for information within five business days, as it is standard for providers to respond to the plan’s request for information in investigating member grievances. This turnaround time is required to ensure that the plan meets its regulatory and accreditation requirements to the member and remains compliant with all state and federal (CMS) requirements.

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