SA-PIHP Grievance Process

Procedure:

1. Receipt of Grievance
   
   
   1. The Grievance Coordinator receives the grievance orally or in writing. Upon receipt of the grievance and verification that the grievance was filed timely the issue is entered into the VO-KS database. VO-KS makes available reasonable assistance for the member with completing forms and taking other procedural steps.  This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.
      
      
   2. The Grievance Coordinator logs the grievance in the database documenting the date received, name of the grievant and nature of the grievance.
      
      
   3. The Grievance Coordinator acknowledges all written or verbal grievances with an acknowledgement letter within five (5) business days of receipt.  The acknowledgement letter includes the VO-KS address and phone number and the expected date of resolution.
      
      
   4. The Grievance Coordinator works toward resolution with other VO-KS staff as necessary, such as:
      
      
      1. Provider Relations
      2. Claims Department
      3. Clinical Operations Department
      4. Regional Offices
         
         
   5. If a potential Quality of Care issue is identified, the case is forwarded to the Director of Quality Management, or designee, for oversight and investigation.
      
      
   6. If a resolution cannot be completed within 14 calendar days, the grievant is contacted either telephonically or in writing prior to the 14th day and is advised of the status of the grievance.
      
      
      1. The resolution timeframe may be extended up to 14 calendar days if the member requests the extension or if VO-KS demonstrates that there is need for additional information and the extension is in the member’s interest.
      2. For any extension not requested by the member, VO-KS shall give the member written notice of the reason for the extension within 2 working days of the decision to extend the timeframe.
         
         
   7. The written resolution response to the member contains all required information including but not limited to:
      
      
      1. All information considered in the investigation of the grievance;
      2. Findings and conclusions based on the investigation; and
      3. The disposition of the grievance.
         
         
   8. The Grievance Coordinator updates the grievance database to include the resolution date of the grievance and the disposition.
      
      
2. Reporting, Tracking, and Trending
   
   
   1. The Director of Quality Management, or designee, is responsible for ensuring the timely resolution of grievances through regular review of the tracking database.
      
      
   2. Grievances are tracked according to the following categories:
      
      
      1. Access to Care/Services
      2. Clinical Issues
      3. Care Disruption Issues/Terminations of Care
      4. Claims/Invoice Issues
      5. Formulary Issues
      6. Quality Issues
      7. Utilization Review Issues
      8. Other categories as needed
         
         
   3. The Director of Quality Management, or designee, reviews all grievances on a monthly basis to identify patterns.
      
      
      1. Action plans are developed as issues are identified.
      2. Patterns of poor quality are forwarded to the VO-KS Clinical Quality Committee as necessary.
         
         
   4. The Grievance Coordinator provides the VO-KS Clinical Quality Committee with monthly summary reports for review and recommendation.
      
      
   5. The Director of Quality Management submits grievance reports to the SRS, as required by contract.
      
      
3. All documentation related to the grievance is maintained through the grievance file in accordance with confidentiality requirements.
   
   
   1. VO-KS documents the following information, (but not limited to):
      
      
      1. Date of filing of grievance;
      2. Name, identifier, and nature of the grievance;
      3. Date of the acknowledgment letter;
      4. Dates of decision to extend the timeframe as well as SRS approval and member notification;
      5. The determination made including the date of the resolution, the title(s) of the personnel and credentials of any clinical personnel who participated in each determination;
      6. Date the resolution letter is mailed to the grievant;
      7. All correspondence between VO-KS and the grievant, including notices of final resolution and all other pertinent information.
         
   2. The grievance file is released to the member (or their representative) upon request as permitted by federal and state confidentiality laws and regulations.

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