Pennsylvania

STEP ONE – Notify Your Health Plan

The first thing you need to do is file a complaint with your health plan. Most health plans in Pennsylvania have a two-level appeal process to handle grievances and complaints. Follow the steps below to file a complaint and appeal with your health plan:

• Call the member/customer service phone number for your health plan.
• Tell them you want to file a formal complaint and then explain the problem.
• You can also file your complaint by letter, email, or online through your health plan’s website (see below).
• If you disagree with your health plan’s decision, you have the right to an internal appeal.

Below are links to the complaint forms for Pennsylvania‘s top health plans:

• Aetna
• Capital Advantage Assurance (Capital Blue Cross)
• Highmark Blue Cross Blue Shield (Medicare)
• Independence Blue Cross
• Geisinger Health Plan
• Geisinger Quality Options
• Keystone First (Keystone Family Health Plan)
• UPMC Health Plan
• UnitedHealthCare
  • Log on to MyUHC.com and complete the “Appeals and Grievance Form”
  • Select: Claims and Accounts > Medical Appeals and Grievances > Member Service Request Form
  • Fax or mail the completed form to the UnitedHealthcare address listed in the instructions
• My plan isn’t listed

Medicare Plans

 

STEP TWO – File a Complaint

You have the right to file a complaint with the Pennsylvania Department of Health and/or the Pennsylvania Insurance Department if you have a problem getting the services you need, including quality and affordable health care. To file a complaint you must first complete your health plan’s appeal process.

The Department of Health reviews appeals that concern quality of care or quality of service issues.

• Call the Department of Health to file a quality complaint: (888) 477-2787 or (888) 466-2787.

The Insurance Department reviews appeals relating to contract exclusions, coverage disputes and other insurance-related issues.

• File a complaint with the Insurance Department online here or request a form here.
• Call the Insurance Department’s helpline: 1 (877) 881-6388.
• You can expect the investigator to contact you within 30 days.