Member Grievances Involving a Provider
Member Grievances and Potential Quality Issues (PQIs) Involving a Provider:
An important feature of Community Care Health’s (CCH) Quality Improvement Program is the investigation and resolution of member grievances. A grievance is a member’s expression of dissatisfaction with any aspect of their health plan, including their health care and/or the delivery of care. Grievance forms and a description of the grievance procedure must be readily available at each contracting provider’s office or facility. Both can be found on CCH’s website at the following link:
If a member grievance involves a provider, CCH may need information from the provider to help resolve the grievance. In those cases, CCH will send a letter to the provider requesting the information and asking the provider to respond within seven (7) business days. If the grievance involves a provider, in many cases it also involves a potential quality issue (PQI). CCH’s process for addressing PQIs is described below.
Potential Quality Issues (PQIs)
A PQI is a suspected deviation from expected provider performance, clinical quality of care, or outcome of care which requires further investigation to determine if an actual quality of care concern or opportunity for improvement exists. While PQIs are identified through multiple sources, many are raised through member grievances.
Upon receipt of a PQI, the CCH Quality Department will send a letter to the provider containing a summary of the issue or allegation and asking the provider to respond within seven (7) business days. Medical records are requested if applicable to the member’s issue. It is important for providers to respond promptly to such requests to ensure that grievances and PQIs are resolved within the timelines established by law.
When applicable, CCH uses responses from providers to identify opportunities to educate members. The responses also highlight opportunities for CCH to work more closely with providers on interactions that are perceived to be problematic by members and to improve CCH’s processes. CCH views every grievance, PQIs and non-PQIs, as a chance to improve the member experience.
Please see attached document for additional information on a Member Grievance Involving a Provider.