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Medicaid Complaints, Grievances, and Fair Hearings



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

Complaints

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

Some things you may complain 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 gotten services that Gateway Health has approved.
  • You were denied a request to disagree with a decision that you have to pay your provider.

Grievances

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

A Grievance is when you tell Gateway Health you disagree with Gateway Health’s decision.


Fair Hearings

In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something Gateway Health did or did not do. These hearings are called “Fair Hearings.” You can ask for a Fair Hearing after Gateway Health decides your First Level Complaint or decides your Grievance.

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