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Grievance and Appeals Process

The grievance process allows the member, (or the member’s authorized representative (family member, etc.) acting on behalf of the member or provider acting on the member’s behalf with the member’s written consent), to file a grievance either orally or in writing, at any time. A member grievance is defined as any member expression of dissatisfaction about any matter other than an “adverse action.”

Oklahoma Complete Health will let you know we have received your grievance by sending you an acknowledge letter receipt of each grievance within 10 calendar days.

Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Oklahoma Complete Health shall ensure that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease. Oklahoma Complete Health values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.

Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not to exceed 30 calendar days from the date of the initial receipt of the grievance. If you need additional time to submit information about your grievance, you are allowed to as us for a 14-day extension. We will extend the resolution of your grievance up to 14 days should we need additional time that is in your best interest. We will notify you in writing within 3 days of determining an extension is needed. Once we have completed the review of your grievance, we will send you a response in writing within 30 calendar days, not to exceed the 14 days of the extension.

To request a Grievance, you can:

                Oklahoma Complete Health

                ATTN: Grievance and Appeals

                PO Box 10353

                Van Nuys, CA 91410-0353

Medical Necessity Appeals
An appeal is the request for review of a “Notice of Adverse Action.”  A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Oklahoma Complete Health network.  

Appeal Resolution Time Frame
Members may request that Oklahoma Complete Health review the Notice of Adverse Action to verify if the right decision has been made. The member may authorize someone else to appeal for them, the authorization must be received in writing. The request for an appeal may be made orally or in writing. Standard appeal requests will be resolved within 30 calendar days of receipt of the appeal. The timeframe may be extended by 14 calendar days if additional information is required.

Expedited appeals may be filed when either Oklahoma Complete Health or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.

Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. Oklahoma Complete Health may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Oklahoma Complete Health provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest.

For any extension not requested by the member, Oklahoma Complete Health shall provide written notice to the member of the reason for the delay. Oklahoma Complete Health shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.

To request an Appeal, you can:

            Oklahoma Complete Health

            ATTN: Grievance and Appeals

            PO Box 10353

            Van Nuys, CA 91410-0353

 

Last Updated: 05/02/2024