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3.

Policy and Procedure No.: 13.3 Page 2 of 4

POLICY:

Provider Relations will ensure that all questions, complaints and grievances are handled within the specified time periods by the appropriate section of the Office of Managed Care (OMC).

PROCEDURE

RESPONSIBILITY

ACTION

Informal Complaints:

PROVIDER RELATIONS GRIEVANCE COORDINATOR

1

Receives question or complaint from provider in writing, in person, or by telephone and informs the provider of his/her right to file an Informal Complaint or Formal Grievance.

Note: If complaint suggests care or clinical issue, it will

Clinical

Grievance.

Clinical

a quality of be handled Grievances

as a are

forwarded resolution the same

to Medical Administration for and are processed according to time line as Formal Grievances.

2.

Records grievance code into Informal

Complaint/Grievance

Log

(Attachment

I).

Interviews provider to obtain specifics of the question or complaint and attempts to resolve the issue to the provider's satisfaction.

4,

Contacts appropriate OMC assistance with resolution,

Secfion(s) for if necessary.

5.

Collects information from appropriate OMC Section, if required, and informs provider of resolution.

If complaint is received in person or over the telephone, Provider Relations responds orally within seven (7) calendar days.

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