Complaints and Grievances

These are the Commonwealth of Pennsylvania’s definitions for both a complaint and a grievance as they pertain to Medicaid behavioral health services. Please choose the topic that best applies to your current needs. Once you select an option, you will find more information.

• A complaint is a dispute or objection filed with the Behavioral Health Managed Care Organization (BH-MCO) regarding a participating health care provider or the coverage, operations, or management policies of a BH-MCO.

• A grievance is a request to have a BH-MCO or utilization review entity reconsider a decision concerning the medical necessity and appropriateness of a health care service.

In accordance with federal and state changes to Medicaid managed care regulations, Community Care has made changes to its complaint and grievance processes. These changes will take effect on September 1, 2018. For more information, call us.

Professional Advisors (Peers) are available via telephone to discuss denials based on medical necessity during normal business hours and outside of normal business hours subject to reasonable limitations of availability. Adverse benefit determinations are available for discussion from the time of the denial until any initiation of the formal grievance process. Contact Customer Service at 888-251-2224.