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Grievance

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Grievance means any expression of dissatisfaction about any matter other than an adverse benefit determination (ABD), and may include, but is not limited to: the quality of care or services provided, aspects of interpersonal relationships with a provider or contractor’s employee, failure to respect a member’s rights regardless of whether remedial action is requested, and the right to dispute an extension of time proposed by contractor to make an authorization decision. A complaint is the same as grievance. An inquiry is a request for more information that does not include an expression of dissatisfaction. Inquiries may include, but are not limited to, questions pertaining to eligibility, benefits, or other contractor processes.

 

Last Updated: 07/01/2024