Grievance and Appeal System

The grievance process allows the member, or the member’s authorized representative (family member, friend, provider, etc.) acting on behalf of the member, to file a grievance either orally or in writing. A grievance is defined as any expression of dissatisfaction about any aspect of care other than an “adverse benefit determination.”

Care1st acknowledges receipt of each grievance orally or in writing (based on the manner in which the grievance is received and the grievant’s preference).  As to grievances involving clinical issues or grievances related to denial of expedited resolution of an appeal, Care1st ensures that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406]

Care1st values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.

Grievance Resolution Time Frame

Grievance Resolution will occur as expeditiously as the member’s health condition requires.  Most grievances are resolved within 10 business days and all grievances are resolved within 90 calendar days from the date of the initial receipt of the grievance. Expedited grievance reviews will be available for members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 72 hours.

Member Grievance Policy (PDF)

An appeal is the request for review of an “Adverse Benefit Determination.”  An Adverse Benefit Determination is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Care1st network.  

Appeal Resolution Time Frame

The review may be requested in writing or orally. Standard appeals are resolved within 30 days of receipt of the appeal, with a 14-day extension possible if additional information is required. Appeals submitted by a provider, on behalf of a member, MUST be accompanied by an Authorization of Representation signed and dated by the member, giving consent to be represented by the provider.

Care1st screens all appeals for possible expedited resolution. Expedited resolution will be provided when either Care1st or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal will be resolved within the standard timeframe.

Resolution of expedited appeals are completed as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. Care1st may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Care1st determines that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, Care1st provides written notice to the member of the reason for the delay. Care1st makes reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.

Member Appeal Policy