Complaints and Grievances

The Gateway Health Plan^® (“Gateway”) Provider Appeal Committee will resolve all first level appeals as soon as possible after receipt of all necessary information, but no more than thirty (30) calendar days from the date received. The Appeal Committee will be comprised of two (2) or more Gateway staff members who were not involved in the initial review. The First Level Appeal Committee will inform the provider of its decision in a written decision notice.

Second Level Appeal

If the provider is not in agreement with the first level appeal decision, the provider may request a second level appeal. The provider must submit a written request for a second level appeal to Gateway within thirty (30) calendar days of the date of the first level appeal decision letter. The appeal committee will be comprised of two (2) or more staff members who were not involved in any previous level of review. The provider will have the opportunity to participate in person or by telephone conference call in the second level appeal review. The provider must notify the Appeal Coordinator in writing of the intent to participate. The Appeal Coordinator will provide written notice of the hearing date at least fifteen (15) days in advance.

All second level appeals will be resolved within forty-five (45) days from the date received. The Second Level Appeal Committee will inform the provider of its decision in a written decision notice. The decision of the Second Level Appeal Committee is final and binding.

Member Complaint Process

Gateway provides a two-level internal complaint process for its members. Members may file complaints with Gateway regarding issues such as quality of care, quality of service and non-covered benefits. A provider may file a complaint on the member’s behalf, but must be officially appointed as the member’s representative to do so. Gateway will require that documentation is submitted to demonstrate said appointment prior to initiating complaint proceedings.

For first level complaints, the filing limit varies depending upon the issue of the complaint. The complaint must be filed within forty-five (45) days of the following events: plan failure to decide a complaint or grievance within specified timeframes, plan failure to meet timeframes for providing a service or item; dispute of a non-covered benefit denial; dispute of a denial for payment because the service was provided without an authorization by a non-par provider after the service has been rendered; dispute of payment for a service that was denied because it is not a covered benefit but has already been provided. There is no filing limit for any other type of complaint. First level complaints are resolved within thirty (30) days of receipt, and a letter explaining the outcome is mailed to the member and/or member’s appointed representative.

If a member or member’s representative is not satisfied with the outcome of a first level complaint, a second level complaint may be filed within forty-five (45) days from the date of receipt of the notice from the first level complaint committee. Second level complaints are reviewed within forty-five (45) days, and a letter explaining the outcome is mailed to the member and/or member’s appointed representative.

If a member is receiving a service or item that is being reduced or terminated, and a complaint is filed within ten (10) days of the date on the denial notice, Gateway will continue to cover those services during the complaint process.

External Complaint Review

If a member or member’s representative is not satisfied upon the exhaustion of the internal complaint review process, an external complaint may be filed with the Department of Health or Department of Insurance. Members must ask for an external review within 15 days of the date they receive the 2nd level complaint decision letter. These options and instructions are included in any notice from the Gateway Second Level Complaint Committee.

Expedited Complaint

If a member or member’s representative believes that the usual timeframes for review of a complaint would endanger the member’s life, health or ability to regain maximum function, an expedited complaint review may be requested. Whether the member or the provider files such a request, a physician or dentist must submit written certification of emergent need. Please refer to the Forms and Reference Materials Section of this manual for the Certification of Need for Expedited Appeal Form that may be used for this purpose. Gateway will issue a decision on an expedited complaint request within forty-eight (48) hours of receiving the certification.

More information on the member complaint process can be found on our website, www.gatewayhealthplan.com.

Member Grievances
Member Grievances: The First Level

A grievance is defined as a request to have Gateway reconsider a decision based solely upon the medical necessity and appropriateness of a healthcare service. The member, member’s representative, or provider with member’s written consent may file a grievance with Gateway.

Grievances may be filed to request the review of the following types of decisions:

Denial, in whole or in part, of payment for a service if based upon lack of medical necessity;
Denial or limited authorization of a requested service, including the type or level of service;
Reduction, suspension or termination of a previously authorized service;
Denial of the requested service but approval of an alternative service.

The member must file a grievance within forty-five (45) days of the utilization management decision or from the date of receipt of notice about the utilization management decision.

If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.)

Gateway will send written confirmation of receipt of the grievance to the member, the member’s representative and the provider. The notice will include the following information:

The classification of the matter under review as a grievance. The member, representative or provider may question the classification by contacting the Pennsylvania Department of Health;
The member may appoint a representative to act on his or her behalf at any point during the process;
The member, representative, or provider that filed on the member’s behalf, may review information related to the grievance upon request and submit additional information to be considered by the plan;
The member or representative may request the aid of a Gateway staff member who has not been involved in the matter under review.

The First Level Grievance Committee will conduct the review. The members of the Committee will not have been involved in any prior decision related to the grievance. The Committee will include a licensed physician or an approved, licensed psychologist of the same or similar specialty who would typically manage or consult on the healthcare service in question. Gateway will provide to the member, representative or provider access to all information relating to the matter under grievance review and will provide a copy of all material that is available as it pertains to the grievance. The member, representative or provider may specify the remedy or corrective action being sought.

Upon request, Gateway will provide at no charge to the member the assistance of a staff member who has not participated in any decision-making on the decision under review.

Gateway will commence its review, arrive at its decision, and issue a written decision notice within thirty (30) days of receiving the grievance. The member may request a fourteen (14) day extension if needed. The written decision notice will include the basis for the decision and the procedures for the appellant to request a second level review, including the following:

A statement of the issue reviewed by the First Level Committee;
The reasons for the decision;
References to the provisions on which the decision is based and how to obtain these documents, if used;
An explanation of the scientific or clinical judgment for the decision;
An explanation of how to request a second level review, which must be filed within forty-five (45) days of receipt of the first level decisions.

Member Grievances: The Second Level

Within five (5) business days of receiving a request for a second level grievance review, Gateway will send the member an explanation of the procedures followed during the second level grievance. This notice will include that the member may contact Gateway Member Services to request the aid of a staff member who has not participated in any previous decision making regarding the issue under dispute as well as notice of the right to appear before the review committee and that Gateway will provide fifteen (15) days notice of the date and time scheduled for the review.

The Second Level Grievance Committee will be comprised of three (3) or more individuals who did not previously participate in the decision to deny coverage or payment for the issue in dispute. The Committee will include a licensed physician or an approved, licensed psychologist in the same or similar specialty that would typically provide or consult on the healthcare service in question. The second level grievance process allows the member, representative and/or provider to be present at the second level review and to present a case.

Gateway will make reasonable accommodation to facilitate the participation of the member, representative, and/or healthcare provider by conference call or in person. Gateway will take into account the member’s access to transportation and any known disabilities or language barriers. If the member, representative or healthcare provider cannot appear in person, Gateway will allow the opportunity to communicate with the Committee by telephone or other appropriate means.

Attendance at the Second Level Grievance Committee meeting will be limited to the following:

Members of the review committee;
Appropriate plan representatives;
The member, member’s representative, including any legal representative and/or any attendee necessary for the member to participate in or understand the proceedings;
The healthcare provider, and
Applicable witnesses.

The Committee members may not discuss the case to be reviewed prior to the Second Level Committee meeting. A Gateway attorney may attend the meeting to represent the interests of the Committee, but may not argue Gateway’s position or represent Gateway or its staff. The Committee may question the member, the member’s representatives and the healthcare provider. The Committee will base its decision based solely upon the materials and testimony presented at the review. The proceedings will be recorded electronically and then transcribed. The transcription will be included as a part of the permanent record to be forwarded upon request for an external review.

Gateway will complete the second level grievance review, arrive at its decision, and issue a decision notice within forty-five (45) days of its receipt. The member may request a fourteen (14) day extension if needed.

Gateway’s written notice will be provided to the member, representative and healthcare providers and will include the following information:

A statement of the issue under review by the Second Level Grievance Committee;
The reason for the decision;
References to the provisions on which the decision was based and how to obtain these documents, if used;
An explanation of the scientific or clinical judgment for the decision.

Expedited Grievances (Internal)

The member, member’s representative, or healthcare provider with written consent of the member can file an Expedited Grievance with Gateway. Members may call Member Services at 1-800-392-1147. The Expedited Grievance process is provided for use in instances when the member’s life, health or ability to regain maximum function would be placed in jeopardy by the delay occasioned by the standard review process. The member’s physician must provide written certification of the need to expedite the process. The certification must include the clinical rationale and facts to support the physician’s opinion.

The expedited grievance will be committed to writing and will be reviewed by the committee under the same requirements as the Second Level Grievance process previously described with the following exceptions:

The review and decision is completed within forty-eight (48) hours.
If the member, member’s representative, or appealing provider does not attend the hearing, all information presented at the hearing is read into the record, including any report obtained from a physician of same or similar specialty. A copy of the report is available upon request.
It is the responsibility of the member, the member’s representative or the appealing provider to submit information to Gateway within the time constraints of the expedited grievance process.

Following the hearing, Gateway will telephone the member, member’s representative and provider with its decision. A written notice will follow that explains the rationale for the decision, including any clinical rationale and the procedure for obtaining an Expedited External Grievance or Expedited Department of Public Welfare (DPW) Fair Hearing.

Expedited Grievances (External)

A member may contact Gateway’s Member Services Department to request an external grievance review. For Expedited External Grievance reviews, Gateway is required to notify the Pennsylvania Department of Health (DOH) within twenty-four (24) hours of receipt of such a request made by a member, member’s representative or provider with member’s written consent. DOH will assign a Certified Review Entity (CRE) within one (1) business day of receiving the request. The CRE will have two (2) business days following receipt of the case file to make its decision. The CRE will inform all parties involved of its decision in writing.

External Grievances (Standard)

Pursuant to Pennsylvania Act 68, a member, member’s representative or provider with the written consent of the member, may file an External Grievance following the denial of a Second Level Grievance. The member has fifteen (15) calendar days from receipt of the Second Level Grievance decision notice to request an External Grievance. Gateway will notify DOH that an External Grievance has been requested within five (5) business days of receiving such a request. DOH will inform all parties of the name, address and phone number of the CRE assigned within two (2) business days.

DPW Fair Hearing

At any time during the complaint or grievance process and for the period of up to thirty (30) days following any Gateway decision notice, a member may request a Fair Hearing with the Pennsylvania Department of Public Welfare (DPW). The request must be filed in writing to the Department of Public Welfare at the following address:

Department of Public Welfare
OMAP – HealthChoices Program
Complaint, Grievance and Fair Hearings
P.O. Box 2675
Harrisburg, PA 17105-2675

The request must include a copy of the written notice of decision that is the subject of the request.

If the request for a fair hearing is filed by a healthcare provider on behalf of a member, the request must include the member’s written consent to do so. The request must be submitted within thirty (30) calendar days of any Gateway decision notice. The Department of Public Welfare will not consider provider appeals for payment regarding managed care organization decisions.

If the request for fair hearing is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.)

The party requesting the fair hearing is expected to be available for participation in the hearing either in person or by telephone. Failure to appear for the hearing will result in dismissal of the case. An Administrative Law Judge (ALJ) assigned to the case acts as the hearing officer and will make a determination as to whether the health plan’s decision to deny services was correct based on the evidence and testimony provided by all parties at the hearing. Fair Hearing decisions are typically issued within sixty (60) to ninety (90) calendar days from the date the request was filed.

If the decision is in favor of the member, Gateway will immediately authorize the service(s) or process the claim(s) for payment. If the decision is in favor of the plan, the member or authorized representative will be given the opportunity to request a Reconsideration by the Secretary of the Department of Public Welfare.

If the provider believes that the member’s life, health or ability to attain, maintain or regain maximum function would be placed in jeopardy by following the standard DPW Fair Hearing process, an expedited Fair Hearing may be requested. In order to do this, the provider must submit written certification with respect to the expedited need for review to DPW. This certification should be faxed to DPW at 717-772-6328. The provider may also call DPW at 1-800-798-2339 to ask for an expedited Fair Hearing. If written certification is not submitted, the provider may testify at the hearing to explain the need for an expedited fair hearing. A member who files a request for an expedited Fair Hearing must continue to receive the disputed service/item at the previously authorized level pending resolution of the DPW Fair hearing, if the request for an expedited Fair hearing is hand delivered or post-marked within ten (10) days from the mail date on the written notice of decision.

The Bureau of Hearings and Appeals will contact the provider and/or member to schedule the expedited fair hearing. The expedited fair hearing will be held by telephone within three (3) business days of the receipt of the request. If the provider 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 the hearing request was received. If the provider submits a written statement or testifies at the hearing, the decision will be made within three (3) business days after the fair hearing was held.

Provider Initiated Member Grievances

Pursuant to Pennsylvania Act 68, with the written consent of the member, a provider may file an appeal in the member’s stead. Providers may request the member’s written consent to appeal prior to treatment, but it can not be a requirement for treatment to be provided. The regulatory requirements for providers to pursue a grievance as well as the timeframes for member notice of a provider to pursue or discontinue pursuit of a grievance must be included in the consent. In this situation, the rights afforded the member under the Act 68 grievance process is transferred to the provider. It is important to note that the member may rescind consent at any time. The Act 68 process applies to Medicaid members only.

Please note that providers who initiate the Act 68 grievance process may not make use of the provider appeal process, as previously outlined, to request a review for the same matter.

Provider Responsibilities When Initiating Member Appeals

Medicaid members may not be billed or balance billed for covered services at any time. The member’s consent is automatically rescinded if the provider fails to pursue the grievance and the member may continue the grievance at that point in the process.

The member has the right to ask any person (family, friend, relative, attorney, provider, etc.) to act as a representative during the grievance process. This person is referred to as the “member’s representative.” If the representative is a healthcare provider, the provider must secure and provide to Gateway the member’s written consent to do so. If the member is a minor or legally incompetent, the provider must submit written consent of the parent, guardian, or legally appointed representative in order to pursue a grievance.

An acceptable consent document must contain all of the following components:

The member’s name;
The member’s address;
The member’s identification number;
If the member is a minor or legally incompetent, the name, address and relationship to the member of the person who consents for the member;
The name, address and identification number of the provider to whom the member or representative is granting consent;
The name and address of the plan to whom the member or representative is providing consent;
An explanation of the specific service for which coverage was provided and/or denied to which the consent applies.

The following statements must also be included in the consent document:

The member or the member’s representative may not submit a grievance concerning the services listed in this consent form unless the member or the member’s legal representative rescinds consent in writing. The member or the member’s legal representative has the right to rescind consent at any time during the grievance process.
The consent of the member or the member’s legal representative is automatically rescinded if the provider fails to file a grievance or fails to continue to prosecute the grievance through the second level review process.
The member or the member’s legal representative, if the member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his or her satisfaction. The member or the member’s legal representative understands the information in the member’s consent form.

The document must also contain the dated signature of the member or the member’s legal representative if the member is a minor or is legally incompetent as well as the dated signature of a witness. The member may rescind the consent at any time during the grievance process. If consent is rescinded, the member may continue the process at the point in the process at which consent was rescinded. The member may not file a separate grievance. A member who has already filed a grievance may choose to authorize a provider to pursue the grievance process at any point during the grievance process. A member’s representative carries all the rights conferred upon the member by the Act 68 grievance process.

Provider Initiated Member Grievances: The First Level

Grievances may be filed to request the review of the following types of decisions:

Denial, in whole or in part, of payment for a service if based upon lack of medical necessity;
Denial or limited authorization of a requested service, including the type or level of service;
Reduction, suspension or termination of a previously authorized service;
Denial of the requested service but approval of an alternative service.

The appellant must file a grievance within forty-five (45) days of the utilization management decision or from the date of receipt of notice about the utilization management decision.

Providers who have obtained the member’s consent to file a grievance have a period of ten (10) days from receipt of any denial notice to notify the member or legal representative of its intent to discontinue pursuit of a grievance.

Gateway will send written confirmation of receipt of the grievance to the member, the member’s representative and the provider. The notice will include the following information:

The classification of the matter under review as a grievance. The member, representative or provider may question the classification by contacting the Pennsylvania Department of Health;
The member may appoint a representative to act on his or her behalf at any point during the process;
The member, representative, or provider that filed on the member’s behalf, may review information related to the grievance upon request and submit additional information to be considered by the plan;
The member or representative may request the aid of a Gateway staff member who has not been involved in the matter under review.

Upon request, Gateway will provide at no charge to the member the assistance of a staff member who has not participated in any decision-making on the decision under review.

Gateway will commence its review, arrive at its decision, and issue a written decision notice within thirty (30) days of receiving the grievance. The appellant may request a fourteen (14) day extension if needed. The written decision notice will include the basis for the decision and the procedures for the appellant to request a second level review, including the following:

A statement of the issue reviewed by the First Level Committee;
The reasons for the decision;
References to the provisions on which the decision is based and how to obtain these documents, if used;
An explanation of the scientific or clinical judgment for the decision;
An explanation of how to request a second level review, which must be filed within forty-five (45) days of receipt of the first level decisions.

Provider Initiated Member Grievances: The Second Level

Within five (5) business days of receiving a request for a second level grievance review, Gateway will send the appellant an explanation of the procedures followed during the second level grievance. This notice will include that the member may contact Gateway Member Services to request the aid of a staff member who has not participated in any previous decision making regarding the issue under dispute as well as notice of the right to appear before the review committee and that Gateway will provide fifteen (15) days notice of the date and time scheduled for the review.

Gateway will make reasonable accommodation to facilitate the participation of the member, representative, and/or healthcare provider by conference call or in person. Gateway will take into account the member’s access to transportation and any known disabilities or language barriers. If the member, representative or filing healthcare provider cannot appear in person, Gateway will allow the opportunity to communicate with the Committee by telephone or other appropriate means.

Attendance at the Second Level Grievance Committee meeting will be limited to the following:

Members of the review committee;
Appropriate plan representatives;
The member, member’s representative, including any legal representative and/or any attendee necessary for the member to participate in or understand the proceedings;
The healthcare provider who filed the grievance with the member’s consent, and
Applicable witnesses.

Gateway will complete the second level grievance review, arrive at its decision, and issue a decision notice within forty-five (45) days of its receipt. The appellant may request a fourteen (14) day extension if needed.

Gateway’s written notice will be provided to the member, representative and healthcare providers and will include the following information:

A statement of the issue under review by the Second Level Grievance Committee;
The reason for the decision;
References to the provisions on which the decision was based and how to obtain these documents, if used;
An explanation of the scientific or clinical judgment for the decision.

Expedited Grievances (Internal)

The member, member’s representative, or healthcare provider with written consent of the member can file an Expedited Grievance with Gateway. Members may call Member Services at 1-800-392-1147. Providers may call Provider Services at 1-800-392-1145. The Expedited Grievance process is provided for use in instances when the member’s life, health or ability to regain maximum function would be placed in jeopardy by the delay occasioned by the standard review process. The member’s physician must provide written certification of the need to expedite the process. The certification must include the clinical rationale and facts to support the physician’s opinion.

The review and decision is completed within forty-eight (48) hours.
If the member, member’s representative, or appealing provider does not attend the hearing, all information presented at the hearing is read into the record, including any report obtained from a physician of same or similar specialty. A copy of the report is available upon request.
It is the responsibility of the member, the member’s representative or the appealing provider to submit information to Gateway within the time constraints of the expedited grievance process.

Expedited Grievances (External)

For Expedited External Grievance reviews, Gateway is required to notify the Pennsylvania Department of Health (DOH) within twenty-four (24) hours of receipt of such a request made by a member, member’s representative or provider with member’s written consent. DOH will assign a Certified Review Entity (CRE) within one (1) business day of receiving the request. The CRE will have two (2) business days following receipt of the case file to make its decision. The CRE will inform all parties involved of its decision in writing.

If the provider requests the External Grievance, both Gateway and the provider must establish escrow accounts in the amount of one-half of the estimated cost of the review. If the CRE’s decision is in favor of the member, in whole or in part, Gateway will be responsible for the fee charged by the reviewer, regardless of who filed the grievance. If the decision is wholly in favor of Gateway, and the healthcare provider filed the grievance on the member’s behalf, the provider is responsible for payment to the CRE.

External Grievances (Standard)

Pursuant to Pennsylvania Act 68, a member, member’s representative or provider with the written consent of the member, may file an External Grievance following the denial of a Second Level Grievance. The member, member’s representative or healthcare provider with written consent (referred to as “appellant” in this section), has fifteen (15) calendar days from receipt of the Second Level Grievance decision notice to request an External Grievance. If the provider files the request for an External Grievance, the provider shall forward a copy of the member’s written consent that authorizes the filing of an External Grievance. Gateway will notify DOH that an External Grievance has been requested within five (5) business days of receiving such a request. If the provider requests the External Grievance, both Gateway and the provider must establish escrow accounts in the amount of one-half of the estimated cost of the review. DOH will inform all parties of the name, address and phone number of the CRE assigned within two (2) business days.

Within fifteen (15) days of the request for an external review, Gateway will forward a copy of the case file to the CRE. A listing of all documents provided will also be provided to the member or filing provider. The CRE will inform all parties (including DOH) in writing of its decision within sixty (60) days of receipt of the request. Immediately upon notice from the CRE, Gateway will authorize a healthcare service and pay any claims determined to be medically necessary and appropriate by the CRE. If the decision in an external grievance review is against the healthcare provider in full, the healthcare provider shall pay the fee charged by the CRE. If the decision is in full or in part in favor of the member, regardless of who filed the external grievance, Gateway will pay the fee charged by the CRE.

DPW Fair Hearing

Department of Public Welfare
OMAP – HealthChoices Program
Complaint, Grievance and Fair Hearings
P.O. Box 2675
Harrisburg, PA 17105-2675

The request must include a copy of the written notice of decision that is the subject of the request.

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Last Updated: 7/7/2010