OHA: Step 2

Three Step Complaint Process

Step Two

What to Do Next

First, you need to find out who to contact to duscuss your denial. The denial letter that you received from your health plan may contain this information. If it is not on your denial letter, contact your managed care plan for this information; be sure to ask for that person's direct line. The toll-free number to call your plan should be on your membership card.

Check Your Healthplan Documents

Check your health plan documents for a description of your health plan's grievance process. A health plan customer service representative can send you a complaint or grievance form and guide you in filling it out. You have the right to a timely response, especially if your disagreement is over denied medical services you feel you should receive. The grievance material should tell you how long the health plan can take to respond to both emergency and non-emergency grievances. Each managed care plan's process can vary although State law requires they address and respond to your appeal in between 15 and 30 days.

Understand Your Care Plan

Next, you need to understand your health condition before you can discuss the case with your managed care plan. It is important that you understand exactly what the doctor wants to do and why it is necessary. Read any letters your doctor may have submitted to the plan. A "treatment plan" or "plan of care" might be referred to in the doctor's correspondence.