Customer Service Documents
You will be given notice (adverse benefit determination) when a decision is made that denies your request for services or reduces, suspends or terminates the services you already receive. You have the right to file an “appeal” when you do not agree with such a decision. There are two ways you can appeal these decisions. There are also time limits on when you can file an appeal once you receive a decision about your services. You may ask for an appeal by contacting LRE customer services or your local customer service office.
Your appeal will be completed quickly, and you will have the chance to provide information or have someone speak for you regarding the appeal. You may ask for assistance from Customer Service to file an appeal. A provider or advocate may also ask for an appeal for you.
You have 60 calendar days to file an appeal once you have received the notice that your services were denied, suspended, terminated, or reduced. If you want to continue to receive your same level of services while your local appeal is pending, you have 10 days to include the request with your appeal.
If you file an appeal, you will receive an acknowledgment letter. You will also receive a disposition (decision) letter in no more than 30 calendar days for standard appeal and 72 hours for an expedited (quick) appeal
A grievance is an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect a person’s rights regardless of whether corrective action is requested. Grievance also includes a person’s right to dispute an extension of time proposed by the PIHP to make an authorization decision.
If you are unhappy with your services or supports or the staff who provide them, you can file a grievance any time by calling, visiting, or writing to LRE customer services or your local provider. Assistance is available in completing and filing a grievance by contacting the customer service office.
There is no time limit on when you can file a grievance.
A provider may file a grievance on your behalf (with consent by you/ your legal representative).
If you file a grievance, you will receive an acknowledgment letter. You will also receive a disposition (decision) letter in no more than 90 calendar days from the date you file.