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Grievance and Appeal Process
The purpose of Community Care Associates grievance and appeal process is to give Member’s (or a representative) an opportunity to resolve situations in which a Member is dissatisfied with services, benefits and/or Plan or Affiliated Providers’ policies and procedures. The following steps exist to resolve situations that cannot be resolved directly with an Affiliated Provider or through the Member Services Department.
Level 1
- You or someone else submits a written or verbal complaint to Member Services
- Your complaint is reviewed by the Manager of Member Services or the Medical Director
- You get a letter of decision within five (5) business days
Level 2
- If you are not pleased with the decision made at Level 1, you may appeal to the Chairman of the Grievance Committee
- You or someone else submits a written or verbal appeal to Grievance Committee Chairman
- An appeal must state why you disagree with the Level 1 decision
- When your appeal is received, a letter will be sent telling you of the Grievance Committee meeting date. A meeting will be scheduled within seven (7) business days.
- You and/or someone else may attend or request to appear by teleconference
- You will get a letter of decision within three (3) business days after the meeting (2) business days after the meeting
Level 3
- Is the final grievance level at the health plan and a final determination will be made in writing no later than thirty five to forty five (35-45) calendar days after submission of a formal grievance
- A ten (10) calendar day extension may be required to obtain medical documentation from the health care provider or health care facility.
An expedited grievance is sent when a medical determination is made that the time for a routine grievance review would acutely jeopardize the life or health of a member. An expedited review may be requested from the Plan substantiated by a physician’s statement, orally or in writing. Eligibility of an expedited review will be determined by Community Care Associates based on established criteria. If eligible, a qualified provider will handle the expedited review and a decision will be made within 72 hours. If you do not agree with or do not receive a decision within 72 hours, you may request an expedited external review within 10 days of an adverse determination. For an expedited grievance, contact
Community Care Associates, Inc.
P.O.BOX 44230
Detroit, MI 48244
A Member may submit additional information at any point during the appeals process. A Member may also request an External Review for an adverse determination either before or after a service has been provided. For assistance, Fax : 313-961-3116 .