Complaint and Grievance Process

About PHN

Prevea Health Network is committed to providing patients with access to the highest quality medical care. However, if a complaint or issue arises, procedures are in place to guarantee that you are treated fairly.

This complaint process will be used to resolve complaints involving Prevea Health Network. Complaints, whether directed to the PPO administrator or to a participating provider, will be reviewed according to the procedure outlined below.

Complaint means any dissatisfaction with the administration, provider practices or provision of services, with the exception of claims processing or adjudication by Prevea Health Network that is expressed to Prevea Health Network by, or on behalf of a participating person.

Complaint procedure:

Receipt of Complaints

The Quality Resources Department at Prevea will be responsible for receiving and responding to complaints regarding Prevea Health Network. These complaints can be received by:

Prevea Health Network staff
Phone directly to Prevea Health
Mail
Interoffice mail
Electronic mail (e-mail)

Acknowledgement of Complaints

A Complaint Acknowledgement Letter is sent to the party originating the complaint if it is not received by phone.

Tracking of Complaints

A log of complaints specific to Prevea Health Network will be kept. Information logged will include:

Date the complaint was received
Name of complainant or affected party
Summary of concern
Date complaint sent out to responsible party for response
Date chart requested (if pertinent)
Date chart received (if pertinent)
Date answer provided by responsible party
Date answer received by the responsible party

A copy of the complaint log will be available at Prevea Health Network upon request.

Routing of Complaints

Payor or Claims Issues - Any concerns regarding a claim will be redirected back to Prevea Health Network to assist the person in finding the correct resources to handle their concern.

QUALITY OF CARE ISSUES - Issues regarding the quality of care delivered will be investigated. Findings will be forwarded to the Medical Director of Prevea Health Network for final review.

CUSTOMER COMPLAINTS - These concerns will be investigated and feedback provided to the Administrator of Prevea Health Network for final action.

If any part of the concern needs immediate attention, that portion of the concern is addressed immediately with documentation written on the concern regarding the steps taken and is then forwarded on to the responsible party.

Every attempt will be made to resolve complaints within 30 calendar days of the receipt of the complaint in Quality Resources. Such 30-day period may be extended an additional 30 calendar days. If the complaint has not been resolved within this time period, written notification will be provided to the complainant or the complainant's authorized representative notifying them of the lack of resolution, the reason additional time is needed, and when resolution might be expected.

Prevea Health Network will maintain a log for resolution and follow up of all complaints.

Records File

The PPO Administrator will maintain a record of all complaints received and the action taken with respect to each complaint. The PPO Administrator will retain the record of complaints for three years after final notification to the person of the disposition of the complaint.

Collection, Use, and Disclosure of Protected Health Information

Prevea Health Network may use and disclose health information about participants for health care operations and for their treatment. "Health care operations" includes efforts to track our quality improvement activities.

Participants may give us written authorization to use their health information, or to disclose it to anyone, including themselves, for any purpose. If participants give us an authorization, they may revoke it at any time. We may disclose a participant's health information to a family member, friend, or other person to the extent necessary to help with their health care or with payment for their healthcare. In the event of a member's incapacity or an emergency, we will disclose their health information based on our professional judgment of whether the disclosure would be in their best interest.

Participants have the right to look at or request copies of their health information, with limited exceptions.

We are committed to protecting the confidentiality and privacy of every aspect of service and care across the organization. We have developed, implemented, maintain, and use appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information and to prevent intentional or unintentional use or disclosure in violation of law.

Prevea Health Network
1-866-640-7444 or 920-272-1100