OHA: Step 3

Three Step Complaint Process

Step Three

Resolution of Your Grievance

You should expect a formal written response from the health plan acknowledging your complaint and a description of what the health plan will do to resolve it. You should be advised in writing of the health plan's decision. This response should tell you what was decided and why. If the denial is based on medical necessity or experimental or investigational status of a drug/service/device, the plan must cite the specific criteria used by the plan to deny the service and must offer to you a copy of the criteria upon request. The plan must also supply the specific rationale for a denial based on experimental and investigational status with respect to your specific medical circumstances, upon request. You should also be told what to do if you wish to appeal a decision you feel is not fair. OHA's contact information should be located on the denial letter.

If you receive a phone call or letter informing you that the denial has been overturned and the plan will cover the procedure -- Congratulations!

If your appeal has been denied, you also need a copy of the letter upholding the plan's denial. This letter will outline the process for the next level of appeal. (If you have the right to a voluntary second level of appeal, that appeal will typically be reviewed by a different group of people at the managed care plan). If a final denial is made by the carrier, you must be informed of your right to external appeal, if you have one.