Complaints, Grievances and Fair Hearings

• COMPLAINTS
  • What is a complaint?
  • What should I do if I have a complaint?
  • First Level Complaint
  • What if I don't like Gateway’s decision?
  • Second Level Complaint
  • What happens after I file a second level complaint?
  • External Complaint Review
• GRIEVANCES
  • What is a grievance?
  • What should I do if I have a grievance?
  • What if I don't like Gateway’s decision?
  • Second Level Grievance
  • What can I do if I still don't like Gateway’s decision?
  • External Grievance Review
  • What can I do if my health is at immediate risk?
• Persons with Disabilities
• DEPARTMENT OF PUBLIC WELFARE FAIR HEARINGS
  • What happens after I ask for a fair hearing?
  • What can I do if my health is at immediate risk?
• Advance Directives
• HealthChoices Clinical Sentinel Hotline
• Suggestions for Changes
• Fraud and Abuse
• New Technology: Is it Covered?
• Other Information
• Eligibility

If a provider or Gateway does something that you are unhappy about or do not agree with, you or your representative can tell Gateway or the Department of Public Welfare that you are unhappy or you disagree with what the provider or Gateway has done. This section describes what you can do and what will happen.

You may call Gateway’s toll-free Member Services telephone number at 1-800-392- 1147 (TTY/TDD 1-800-654-5988) if you need help or have questions about complaints, grievances or fair hearings, you may also request utilization review and clinical practice guidelines. You can contact your local legal aid office or call the Pennsylvania Health Law Project at 1-800-274-3258. If you need help getting the local legal aid telephone number, please call Gateway’s toll-free Member Services telephone number listed above.

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A complaint is when you tell Gateway you are unhappy with Gateway or your provider or do not agree with a decision by Gateway.

Some things you or your representative may file a complaint about:

• You are unhappy with the care you are getting
• You cannot get the service or item you want because it is not a covered service or item
• You have not received services that Gateway approved

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What should I do if I have a complaint?

First Level Complaint

To file a complaint, you or your representative can call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) to make your complaint. You may also write down your complaint and send it to Gateway at:

Gateway Health Plan^®
US Steel Tower Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704

Your provider or your representative can file a complaint for you if you give your consent in writing to do so. Please note that if your provider files a complaint for you, you cannot file a separate complaint on your own.

This is called a first level complaint.

When should I file a first level complaint?

1. You or your representative must file a complaint within 45 days of getting a letter telling you that:
   • Gateway Health Plan^® has decided that you cannot get a service or item you want because it is not a covered service or item
   • Gateway Health Plan^® will not pay a provider for a service or item you got.
   • Gateway Health Plan^® did not decide a complaint or grievance that you had reported within 30 days.
2. You or your representative must file a complaint within 45 days of the date you should have received a service or item if you did not get a service or item.
3. You or your representative may file all other complaints at any time.

What happens after I file a first level complaint?

After you or your representative file your complaint, you will get a letter from Gateway telling you that Gateway has received your complaint, and about the first level complaint review process.

You or your representative may ask Gateway to see any information that Gateway has about your complaint. You or your representative may also send information to Gateway that may help with your complaint.

You or your representative may attend the complaint review if you let us know within 10 days of the date of Gateway’s confirmation letter. You or your representative may come to Gateway’s offices or participate by phone or by videoconference. If you decide that you do not want to attend the complaint review, it will not affect Gateway’s decision.

A committee of one or more Gateway staff who has not been involved in the issue will review your complaint and make a decision within 30 days after Gateway receives your complaint.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the First Level Complaint:

If you have been receiving services or items that are being reduced, changed or stopped and you file a complaint that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are not covered services or items for you, the service or items will continue until a decision is made.

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What if I don’t like Gateway’s decision?

Second Level Complaint

If you do not agree with the first level complaint decision, you or your representative may file a second level complaint with Gateway.

When should I file a second level complaint?

You or your representative must file your second level complaint within 45 days of the date you receive the first level complaint decision letter. You may call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) to make your complaint. You may also write down your complaint and send it to Gateway at:

Gateway Health Plan^®
US Steel Tower Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704

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You will receive a letter telling you that Gateway has received your complaint, and telling you about the second level complaint review process.

You or your representative may ask to see any information that Gateway has about your complaint. You may also send any additional information to Gateway that may help with your complaint.

You or your representative may attend the complaint review. Gateway will send you a letter telling you the date and time of the hearing. You or your representative may come to Gateway’s offices or participate by phone or by videoconference. If you decide that you do not want to attend the complaint review, it will not affect Gateway’s decision.

A committee made up of three or more people, who have not been involved in the issue, will review your complaint and make a decision. At least one third of the second level review committee may not be employees of the plan or of a related subsidiary or affiliate. Your complaint will be decided within 45 days after Gateway receives your complaint.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you the reason(s) for the decision and what to do if you don’t like the decision.

What to do to continue getting services during the Second Level Complaint:

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a second level complaint that is hand-delivered or postmarked within 10 days of the date on the first level complaint decision letter, the services or items will continue until a decision is made.

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If you do not agree with Gateway’s second level complaint decision, you or your representative may ask for an external review by either the Department of Health or the Insurance Department. The Department of Health handles complaints that involve the way a provider gives care or services. The Insurance Department reviews complaints that involve Gateway’s policies and procedures.

You or your representative must ask for an external review within 15 days of the date you received the second level complaint decision letter.

You or your representative must send your request for external review in writing to either:

Department of Health
Bureau of Managed Care
Room 912, Health & Welfare Building
7th and Forster Street
Harrisburg, PA 17120-0701
Phone: 1-888-466-2787

Or

Pennsylvania Insurance Department
Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, PA 17120
Phone: 1-877-881-6388

If you or your representative ask, the Department of Health will help you put your complaint in writing.

If you or your representative send your request for external review to the wrong department, it will be sent to the correct department.

The Department of Health or the Insurance Department will request your file from Gateway. You or your representative may also send any other information that may help with the external review of your complaint. This information should be forwarded to either the Department of Health or Department of Insurance and to Gateway.

An attorney or another person may represent you during the external review.

A decision letter will be sent to you after the decision is made. This letter will tell you the reason(s) for the decision and what to do if you don’t like the decision.

What to do to continue getting services during the External Complaint Review:

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a request for an external complaint review that is hand-delivered or postmarked within 10 days of the date on the second level complaint decision letter, the services or items will continue until a decision is made.

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GRIEVANCES

What is a grievance?

When Gateway denies, decreases or approves a service or item different than the service or item you requested because it is not medically necessary, you will receive a letter (notice) telling you Gateway’s decision.

A grievance is when you tell Gateway that you disagree with the decision.

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First Level Grievance

To file a grievance, you or your representative can:

Call Gateway at 1-800-392-1147 (TTY/TDD 1-800-654-5988) to file your grievance, or

Write down your grievance and send it to Gateway at:

Gateway Health Plan^®
US Steel Tower Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704

or  your provider or your representative can file a grievance for you if you give the provider or your representative your consent in writing to do so.

NOTE: If your provider files a grievance for you, you cannot file a separate grievance on your own.

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When should I file a first level grievance?

You or your representative have 45 days from the date you receive the letter (notice) that explains the denial, decrease or approval of a different service or item.

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What happens after I file a first level grievance?

After you or your representative file your grievance, you will get a letter telling you that Gateway has received your grievance and about the first level grievance review process.

You or your representative may ask Gateway to see any information that Gateway has about your grievance. You or your representative may also send any additional information to Gateway that may help with your grievance to Gateway.

You or your representative may attend the grievance review if you request a hearing within 10 days of the date of Gateway’s confirmation letter. You or your representative may come to Gateway’s offices or be included by phone or by videoconference. If you decide that you do not want to attend the grievance review, it will not affect Gateway’s decision.

A committee made up of one or more Gateway staff who have not been involved in the issue will review your grievance and make a decision. One of the committee members will be a licensed doctor or dentist. Your grievance will be decided no later than 30 days after Gateway receives your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you the reason(s) for the decision and what to do if you don’t like the decision.

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What to do to continue getting services during the First Level Grievance review:

If you have been receiving services or items that are being reduced, changed or stopped, and you file a grievance that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are being reduced, changed or stopped, the services or items will continue until a decision is made.

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What if I don’t like Gateway’s decision?

Second Level Grievance

If you do not agree with the first level grievance decision, you or your representative may file a second level grievance with Gateway.

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You or your representative must file your second level grievance within 45 days of the date you receive the first level grievance decision letter. You or your representative can call Gateway at 1-800-392-1147 (TTY/TDD 1-800-654-5988) to file your second level grievance. You may also write down your second level grievance and send it to Gateway at:

Gateway Health Plan^®
US Steel Tower Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704

What happens after I file a second level grievance?

You will receive a letter telling you that Gateway has received your grievance and explaining the second level grievance review process.

You or your representative may ask to see any information Gateway has about your grievance. You or your representative may also send any additional information that may help with your grievance.

You or your representative may attend the grievance review if you want to. You or your representative may come to Gateway’s offices or participate by phone or by videoconference. If you decide that you do not want to attend the grievance review, it will not affect Gateway’s decision.

A committee of three or more people including a doctor or dentist who were not involved in any prior review of your grievance will review your grievance and make a decision. At least one third of the second level review committee may not be employees of the plan or of a related subsidiary or affiliate. Your grievance will be decided no later than 45 days after Gateway receives your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the Second Level Grievance review:

If you have been receiving services or items that are being reduced, changed or stopped and you file a second level grievance that is hand-delivered or postmarked within 10 days of the date on the first level grievance decision letter, the services or items will continue until a decision is made.

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What can I do if I still don’t like Gateway’s decision?

External Grievance Review

If you do not agree with Gateway’s second level grievance decision, you or your representative may ask for an external grievance review.

You or your representative must call or send a letter to Gateway asking for an external grievance review within 15 days of the date you received the second level grievance decision letter. Use the same address and phone number you used to file your first level grievance. Gateway will then send your request to the Department of Health.

The Department of Health will notify you of the external grievance reviewer’s name, address and phone number. You will also be given information about the external review process.

Gateway will send your grievance file to the reviewer. You or your representative may provide additional information to the reviewer that may help with the external review of your grievance within 15 days of filing the request for an external grievance review.

You will receive a decision letter within 60 days of the date you asked for an external grievance review. This letter will tell you the reason(s) for the decision and what to do if you don’t like the decision.

What to do to continue getting services during the External Grievance Review:

If you have been receiving services or items that are being reduced, changed or stopped and you request an external grievance review that is hand-delivered or postmarked within 10 days of the date on the second level grievance decision letter, the services or items will continue until a decision is made.

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Expedited Complaints and Grievances

If your doctor or dentist believes that the usual timeframes for deciding your complaint or grievance will harm your health, you or your doctor or dentist can call Gateway at 1-800-392-1147 (TTY/TDD 1-800-654-5988) and ask that your complaint or grievance be decided faster. You will need to have a letter from your doctor or dentist faxed to Gateway at 412-255-4503 explaining how the usual timeframe for deciding your complaint or grievance will harm your health. This letter is called a provider certification.

If your doctor or dentist does not include a provider certification when an expedited complaint or grievance is filed, Gateway will notify you that this certification was not received. If Gateway is unable to obtain a provider certification from your doctor or dentist within forty-eight (48) hours of your request for an expedited complaint or grievance, your complaint or grievance will be decided within the usual timeframes.

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Expedited Complaint

A licensed doctor or dentist, who has not been involved in the issue you filed your complaint about, will decide the expedited complaint.

Gateway will call you with Gateway’s decision within 48 hours of when Gateway receives your request for an expedited (faster) complaint review. You will also receive a letter telling you the reason(s) for the decision and what to do if you don’t like the decision.

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Expedited Grievance and Expedited External Grievance

A committee of three or more people, including a licensed doctor or dentist, will review your grievance. The licensed doctor or dentist will decide your expedited grievance with help from the other people on the committee. No one on the committee will have been involved in the issue you filed your grievance about.

Gateway will call you with the decision within 48 hours of receiving the provider’s certification. You will also receive a letter telling you the reason for the decision and how to ask for an expedited external grievance review if you don’t like the decision.

If you or your representative want to ask for an expedited external grievance review by the Department of Health, you must call Gateway at 1-800-392-1147 (TTY/TDD 1-800-654-5988) within 2 business days from the date you got the expedited grievance decision letter. Gateway will send your request to the Department of Health within 24 hours after receiving it.

What kind of help can I have with the complaint or grievance processes?

If you need help filing your complaint or grievance, a staff member of Gateway will help you. This person can also represent you during the complaint or grievance process. You do not have to pay for the help of a staff member. This staff member will not have been involved in any decision about your complaint or grievance.

You may also have a family member, friend, lawyer or other person help you file your complaint or grievance. This person can also help you if you decide you want to appear at the complaint or grievance review. For legal assistance you can contact your local legal aid office by calling 1-800-440-3989. If you need help getting the local legal aid telephone number, please call Gateway’s toll-free Member Services telephone number at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

At any time during the complaint or grievance process, you can have someone you know represent you or act on your behalf. If you decide to have someone represent or act for you, you must tell Gateway in writing the name of that person and how we can reach him or her.

You or the person you choose to represent you may ask Gateway to see any information Gateway has about your complaint or grievance.

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If you ask for language interpreter services, Gateway Health Plan^® will provide the services at no cost to you.

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Gateway will provide persons with disabilities with the following help in presenting complaints or grievances at no cost, if needed. This help includes:

• providing sign language interpreters
• providing information submitted by Gateway at the complaint or grievance review in an alternative format. The alternative format version will be given to you before the review
• providing someone to help copy and present information

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Department of Public Welfare Fair Hearings

In some cases you can ask the Department of Public Welfare to hold a hearing because you are unhappy or do not agree with something Gateway did or did not do. These hearings are called “fair hearings.” You can ask for a fair hearing at the same time you file a complaint or grievance or you can ask for a fair hearing after Gateway decides your first or second level complaint or grievance.

What kind of things can I request a fair hearing about and when do I have to ask for my fair hearing?

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How do I ask for a fair hearing?

You must ask for a fair hearing in writing and send it to:
Department of Public Welfare
Office of Medical Assistance Programs –
HealthChoices Program
Complaint, Grievance and Fair hearings
PO Box 2675
Harrisburg, PA 17105-2675

Your request for a fair hearing should include the following information:

• Member name
• Member social security number and date of birth
• A telephone number where you can be reached during the day
• If you want to have the fair hearing in person or by telephone
• Any letter you may have received about the issue you are requesting your fair hearing for

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You will get a letter from the Department of Public Welfare’s Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing. You will receive this letter at least 10 days before the date of the hearing.

You may come to where the fair hearing will be held or be included by phone. A family member, friend, lawyer or other person may help you during the fair hearing.

Gateway will also participate in the fair hearing to explain why the decision was made or explain what happened.

If you ask, Gateway must give you (at no cost to you) any records, reports and other information Gateway has that is relevant to what you requested your fair hearing about.

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When will the fair hearing be decided?

If you ask for a fair hearing after a first level complaint or grievance decision, the fair hearing will be decided no more than 60 days after the Department of Public Welfare gets your request.

If you ask for a fair hearing and did not file a first level complaint or grievance, or if you ask for a fair hearing after a second level complaint or grievance decision, the fair hearing will be decided within 90 days from when the Department of Public Welfare gets your request.

If your fair hearing is not decided within 90 days from the date that the Department of Welfare receives your request, you may be able to get interim assistance until the decision is made.

What to do to continue getting services during the Fair Hearing:

If you have been receiving services or items that are being reduced, changed or stopped and your request for a fair hearing is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that Gateway has reduced, changed or denied your services or items or telling you Gateway’s decision about your first or second level complaint or grievance, your services or items will continue until a decision is made.

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Expedited Fair Hearing

If your doctor or dentist believes that using the usual timeframes to decide your fair hearing will harm your health, you or your doctor or dentist can call the Department of Public Welfare at 1-800-798-2339 and ask that your fair hearing be decided faster. This is called an expedited fair hearing. You will need to have a letter from your doctor or dentist faxed to 717-772-6328 explaining why using the usual timeframes to decide your fair hearing will harm your health. If your doctor or dentist does not send a written statement, your doctor or dentist may testify at the fair hearing to explain why using the usual timeframes to decide your fair hearing will harm your health.

The Bureau of Hearings and Appeals will contact you to schedule the expedited fair hearing. The expedited fair hearing will be held by telephone within 3 business days after you ask for the fair hearing. If your doctor does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited. Another hearing will be scheduled, and the time frame for the fair hearing decision will be based on the date you asked for the fair hearing.

If your doctor sent a written statement or testifies at the hearing, the decision will be made within 3 business days after your fair hearing was held.

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If you are admitted as a patient to a hospital, you will be asked if you have any Advance Directives. An Advance Directive is any instructions you give about your medical care before medical services are done. Advance Directives are only followed in the future when you are unable to say what medical care you want.

There are two kinds of Advance Directives. One is called a “living will” and the other is called a “durable power of attorney.”

A “living will” spells out what kind of life-sustaining care you want to get in a terminal condition or permanent state of coma.

A “durable power of attorney” for healthcare lists someone who can make healthcare decisions for you. This would be if you could not make and tell people your decisions.

An Advance Directive might be used when a person is in a coma and cannot tell the doctor what type of care he or she wants.

It is your legal right to make Advance Directives about your medical care. It is also something you may want to talk to your doctor about.

Gateway can send you information about policies and the current Pennsylvania law regarding the Patient Self Determination Act. This is the law that covers Advance Directives. Call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) for a copy.

Gateway will notify you, by letter, of any changes in Pennsylvania law about Advance Directives within 90 days of the change.

If you believe that a doctor or hospital has not followed the instructions of your Advance Directive you may contact Gateway to find out how to file a complaint with Gateway or with the Department of Health.

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The Clinical Sentinel Hotline (CSH) is operated by The Department of Public Welfare (DPW) to make sure that your requests for medically necessary care and services sent to Gateway and your Behavioral Health MCO are responded to in a timely manner. The CSH helps all Medical Assistance consumers who are enrolled in the HealthChoices Program.

You can call the CSH Monday through Friday between 9:00 a.m. and 5:00 p.m. To reach the CSH, call 1-800-426-2090. The CSH cannot provide or approve urgent or emergency medical care. If you believe you need urgent or emergency care, you should call your PCP or go to your local hospital.

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If you would like to suggest changes to any of Gateway’s Policies and Procedures, please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5955).

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If you think that someone is using your or another member’s Gateway Health Plan^® ID card to get medical or prescription drug benefits, call Gateway’s Fraud and Abuse Hotline at 412-255-4340 (TTY/TDD 1-800-618-4225). Your name will be kept private unless Gateway is required to share that information. If you are not in the (412) area code, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) to report this activity.

You may also report this information to the Department of Public Welfare’s Medical Assistance Provider Compliance Hotline at 1-866-DPW-TIPS (1-800-379-8477). You can report any provider (for example a doctor, dentist, therapist or hospital) for suspected fraud or abuse for services provided to anyone with an Access card.

• Billing or charging you for services that your health plan covers
• Offering you gifts or money to receive treatment or services for your Access number
• Giving you treatment or services that you don’t need
• Physical, mental or sexual abuse by medical staff

You can call the Hotline and speak to someone Monday through Friday 8:30 a.m. to 3:30 p.m. You may leave a voice mail message at other times. If you don’t speak English, an interpreter will be made available. If you are hearing impaired, you can call the hotline using your TTY device.

You do not have to give your name and if you do give your name, the provider will not be told you called.

You can also report suspected fraud and abuse by using the website:  http://www.dpw.state.pa.us/omap or email omaptips@state.pa.us.  This has been set up so you do not have to give your name also.

To read Gateway's Fraud and Abuse Policy in its entirety, click here.

Recipient Restriction Program

Gateway Health Plan^® and the Department of Public Welfare have the right to restrict members to specific provider types when it has been determined that the member has abused his or her healthcare benefits.

The member may appeal the restriction by submitting to the Department of Public Welfare a written request for a Fair Hearing within 30 days from the date of the letter.

A request for a DPW Fair Hearing must be in writing, signed by the member and sent to:

Department of Public Welfare
Division of Program and Provider Compliance
Bureau of Program Integrity
Recipient Restriction Section
PO Box 2675
Harrisburg, Pennsylvania 17110

Requests by the member, pharmacy or physician for a restriction change must be in the form of a written request that is sent to the Gateway Restriction Liaison. Once the request is received and reviewed, the person requesting the change will be notified of Gateway’s decision.

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Gateway Health Plan^® evaluates new technology to decide if it should be included as a covered benefit. New technology means any skills, equipment or know-how of doing something better.

A committee of Gateway physicians evaluates information on new technology. If they recommend that a new technology be included in Gateway’s benefits package, the recommendation will be shared with Gateway’s Senior Management for more evaluation and approval. The committee may recommend that the new technology be approved on a case-by-case basis.

Gateway has pharmacists and physicians who look at new drugs and new uses for drugs four times a year. New drugs are added to the formulary list on an on-going basis. Drugs may be removed from the formulary four times per year.

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If you would like any information about Gateway including who sits on the Board of Directors, what the education of your doctor is, or the way we plan to improve the care and services to our members through Gateway Health Plan’s^® Quality Improvement Program, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

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The Department of Public Welfare decides if you qualify for Medical Assistance. They also decide what healthcare benefits you get based on your level of assistance. You should call your caseworker at your local County Assistance Office (CAO) if you have any questions about your Medical Assistance coverage of healthcare package.

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