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Member Satisfaction Plan Definitions

For purposes of the HealthPlus Member Satisfaction Plan, the following definitions shall apply:

Adverse Determination

A HealthPlus coverage determination that an admission, availability of care, continued stay or other health care service or benefit has been reviewed and denied, reduced or terminated. Failure to respond in a timely manner to a request for a determination constitutes an adverse determination.

Expedited Grievance

A grievance in which a physician substantiates (orally or in writing) that due to the medical status of the member, resolution within HealthPlus’ normal time frames would acutely jeopardize the life or health or ability to regain maximum function of a member or subject a member to severe pain that cannot be managed adequately.

Grievance

A dispute on behalf of a member, presented orally or in writing by the member (or another person, including a physician, who is authorized in writing to act on behalf of the member), regarding the availability, delivery or quality of health care services (including an adverse determination concerning utilization review), pre-service or post-service claims; payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a member and HealthPlus.

The grievance process does not apply to a provider’s complaint concerning claims payment, handling or reimbursement for health care services.

The Member Satisfaction Coordinator will assure the routine grievance process takes no longer than 30 days from filing of the grievance to the final written determination made by the Grievance Appeal Committee. This 30-day period may be tolled, however, by a member or by HealthPlus for up to 10 days.

The HealthPlus Member Satisfaction Plan is available to all HealthPlus members. However, members in the HealthPlus MedicarePlus Program must have all payment or service denials reviewed under the HealthPlus Subscriber Appeal Process which is mandated by the Centers for Medicare and Medicaid Services and described in HealthPlus MedicarePlus member materials.

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