Complaints Grievance & Appeals

Which is NOT an Option for Quality of Service Complaints

• Quality of Practitioner Office

• Access

• Attitude and Service

• Quality of Care

If another Member on a policy is filing an Appeal for someone, we need the Member to sign a DOR Form

• True

• False

• Lack of available appointments, wait time to obtain an appointment is an example of what type of Complaint

• Billing/Financial

• Access to Care

• Attitude and Service

• Quality of Practitioner Office

• Provider was rude and used abusive language, tone, or attitude is an example of what type of Complaint

• Billing/Financial

• Access to Care

• Quality of Practitioner Office Site

• Attitude and Service

Complaints must be resolved in

• 48 Hours

• 72 Hours

• Same Day

• 10 Days

complaints that are filed based on the member’s perception that the care they received was medically inappropriate is called what?

• Grievance

• Quality of Service

• Quality of Care

• Appeal

If a member wants us to Change any decision that we have made, they would need to file a what?

• Complaint

• Grievance

• Appeal

• One Day Grievance

a formal complaint or dispute regarding a decision made by Anthem that is not related to medical necessity is called what

• Grievance

• Appeal

• Complaint

• One Day Grievance

If a member has done everything they can to see an In Network Provider but Services beyond their control are sent OON, what can we file for the member?

• Grievance

• Appeal

• AEG Adjustment

• Complaint

When one Family member would NEVER pay more than their own Deductible amount to Obtain Co-Insurance is called