Grievances

This section gives the rules for making a grievance (complaint). State law says you can make a grievance about any part of your medical care as a Delaware First Health member. The state has helped set the rules about what you need to do to make a complaint. The state also has rules about what we must do when we get a grievance. We must be fair in handling your grievance. You cannot be dropped from the plan for filing a grievance. We will not penalize you for making a complaint.

Let us know right away about any problems you have with your healthcare services. Call Member Services at 1-877-236-1341 (TTY: 711). Let us know if you need an interpreter.

What is a Grievance?

A “grievance” is a complaint that you make to your plan about your healthcare. A grievance can cover anything you are unhappy about, except for an adverse benefit determination made to Delaware First Health by a member or their authorized representative. Members may file grievances regarding the quality of care or service received. You, or someone you choose to help you, may file a grievance by phone or in writing. Delaware First Health can help you fill out forms to file a grievance or an appeal.

A grievance may be about anything you are unhappy with while getting services as a member of Delaware First Health. Some examples are:

• Unclear or wrong information from staff.
• Poor quality of care or access to care.
• Rudeness from a provider or employee.
• Failing to respect your member rights.
• Unpaid medical bills.
• Wait time to see your PCP/specialist.
• Eligibility issues.
• Pharmacy issues.

 

How to File a Grievance

You can file a grievance at any time by:

• Calling Member Services at 1-877-236-1341 (TTY: 711). We are here for you Monday through Friday, from 8 a.m. to 7 p.m., Eastern time. Translation services are also available if needed.
• Sending a fax to 1-833-525-0054.
• Writing to:

Delaware First Health

ATTN: Appeals and Grievances

P.O. Box 10353

Van Nuys, CA 91410-0353

Be sure to include:

• Your first and last name.
• Your Medicaid or Delaware First Health ID number.
• Your address and telephone number.
• What made you unhappy.
• Where did the incident take place.
• The provider’s information (name, address, and telephone number).
• What you would like to have happen.

There is also a grievance form that you can use on our website at DelawareFirstHealth.com/Grievance.

If you want someone to file a grievance for you, we need your written permission. This will make them an authorized representative. We have a form you need to use to give someone else permission. You can find this on our website at DelawareFirstHealth.com. You can also call Member Services and ask for the form. The form is titled “Grievance and Appeals Authorized Representative Designation.” Parents or guardians of minors do not need to fill out this form.

Delaware First Health will not treat you differently for filing an appeal or grievance.

What to Expect After You File a Grievance

We will send you a letter within five business days after you file a grievance to let you know we got it. If you have information to help us with your grievance, please send it to us by calling, faxing, or mailing it in. You can request copies of the documents we used to resolve your grievance free of charge.

We will send a resolution letter to you within 30 calendar days, which will inform you of our decision.

If more information is needed to resolve your grievance, a 14-calendar day extension may be requested by Delaware First Health. We will only ask for an extension if it is in your best interest. If more time is needed, we will let you know by phone and in writing at least two calendar days before the 30 calendar days are up. You may file a grievance if you disagree with the extension. You can also request an extension if you need more time to support your grievance. If you want an extension, please call Delaware First Health Member Services at 1-877-236-1341 (TTY: 711).

Timeframe for Filing a Grievance

You, your authorized representative, or your provider (with your written consent) may file a grievance at any time. Delaware First Health must resolve your grievance within 30 calendar days of receipt.

Within five business days of receiving your grievance, we will mail you a letter acknowledging your grievance. We will send you a resolution letter within 30 calendar days of receipt of your grievance.

Appeals

What Is an Appeal?

An appeal is a request for your health plan to review a decision made to deny, terminate, or reduce a benefit. You, your authorized representative, or your provider (with your written consent) may request an appeal by:

• Calling Member Services at 1-877-236-1341 (TTY: 711).
• Sending a fax to 1-833-525-0054.
• Writing to:

Delaware First Health

ATTN: Appeal Coordinator

P.O. Box 10353

Van Nuys, CA 91410-0353

If you are appealing behavioral health services, send your request:

• In writing to:

Delaware First Health

ATTN: Appeal Coordinator

P.O. Box 10378

Van Nuys, CA 91410-0353

• By fax: 1-866-714-7991

If you are appealing a pharmacy service, send your request:

• In writing to:

Delaware First Health

ATTN: Pharmacy Appeals

P.O. Box 31398

Tampa, FL 3361-3398

• By fax: 1-888-865-6531

You can also submit an appeal request on our secure member portal at DelawareFirstHealth.com. If you are unable to appeal for yourself, you have the option to designate someone else as an authorized representative to do it on your behalf. This person can be your provider, family member, or friend. You must have a written request authorizing them to appeal on your behalf.

When you file your appeal, you should include:

• Your name and member ID number.
• Your phone number.
• Your address.
• What you are appealing.
• Why you are appealing.

If you need help asking for an appeal or understanding the process, call Member Services at 1-877-236-1341 (TTY: 711). We can help you file your appeal. If you need a translator, we can find one for you free of charge.

There is only one level of appeal with the plan. We will send you a letter within five business days to confirm that we have received your appeal. The letter will provide additional details about the appeal process.

You have the right to submit comments, documents, or other information relevant to your request with your appeal request. You, or your authorized representative, have the right to speak or present information to the person or people reviewing your appeal. This can be done in person or over the phone. You have the right to take part in the appeal committee when you ask for an appeal. You have the right to request a copy of your appeal file free of charge.

An appeal committee will review your appeal and make a decision. The appeal committee consists of a staff member from the State of Delaware, a plan medical director, and a plan nurse. The committee members will not have been involved in the previous decision.

We will send you a letter letting you know our decision within 30 calendar days of getting your request for an appeal. If your appeal request is not approved, the decision letter will also explain your rights to request a State Fair Hearing.

If the plan does not make an appeal decision within the 30-calendar day timeframe, you can request a State Fair Hearing.

Timeframe for Filing an Appeal

You, your authorized representative, or your provider (with your written consent) may request a fast (expedited) or standard appeal within 60 calendar days of when Delaware First Health notifies you about a decision to deny, terminate, or reduce a service.

Expedited Appeals

A fast (expedited) appeal may be requested if the normal timeframe to review your appeal could cause you serious health concerns. You, your authorized representative, or your provider may request a fast appeal by:

• Calling Member Services at 1-877-236-1341 (TTY: 711).
• Sending a fax to 1-833-525-0054.
• Writing to:

Delaware First Health

ATTN: Appeal Coordinator

P.O. Box 10353

Van Nuys, CA 91410-0353

You can also submit an appeal request on our secure member portal at DelawareFirstHealth.com.

If you are appealing behavioral health services, send your request:

• In writing to:

Delaware First Health

ATTN: Appeal Coordinator

P.O. Box 10353

Van Nuys, CA 91410-0353

• By fax: 1-866-714-7991

If you are appealing a pharmacy service, send your request:

• In writing to:

Delaware First Health

ATTN: Pharmacy Appeals

P.O. Box 31398

Tampa, FL 3361-3398

• By Fax: 1-888-865-6531

 

If we agree that you should get a fast appeal decision, you will get a decision within 72 hours after Delaware First Health receives your request. If we do not agree, we will notify you by phone that your appeal will follow the standard appeal process. We will send you a written notice within two calendar days. Your doctor may send supporting notes requesting a fast appeal for Delaware First Health to reconsider giving you a fast decision on your appeal.

If you need help asking for an appeal or understanding the process, call Member Services at 1-877-236-1341 (TTY: 711). We can help you file your appeal. If you need a translator, we can arrange one for you free of charge.

Expedited Appeal Process

You have the right to submit comments, documents, or other information relevant to your request with your appeal request. The timeframe to submit additional information is limited due to the quick timeframe to resolve an expedited appeal. You or your authorized representative has the right to speak or present information to the person or people reviewing your appeal. This can be done in person or over the phone. You must request to take part in the appeal meeting when you ask for an appeal.

An appeal committee will review your appeal and decide. The appeal committee consists of a staff member from the State of Delaware, a plan medical director, and a plan nurse. The committee members will not have been involved in the previous decision.

We will notify you of a decision via phone and written letter within 72 hours of when we receive your appeal request. If we do not approve your request during the appeal review, the appeal decision letter will explain your rights for a State Fair Hearing.

14-Day Extension Process

You may ask for an extension, or Delaware First Health may ask for an extension if there is a need for additional details.

When Delaware First Health asks for an extension, the plan will do the following:

• Notify you by phone that an extension is needed.
• Send you a written notice within two calendar days of the decision to extend the timeframe.
• Inform you of your right to file a grievance if you disagree with the decision to extend the timeframe.
• Resolve the appeal as quickly as possible but no longer than the date the extension expires.

Continued Benefits

If we are going to reduce or stop a service that we already approved, you can keep getting benefits during the appeals and State Fair Hearing process. To have your benefits continue you must:

• File an appeal within 10 calendar days of the date your denial letter was mailed.
• OR file an appeal on or before the date your services are set to be discontinued.

The service will stop if:

• You withdraw your appeal or State Fair Hearing request.
• You did not ask for a State Fair Hearing for continued benefits within 10 calendar days of when your appeal decision letter was mailed.
• A State Fair Hearing decision was made against you.

In accordance with federal policy, if the decision of the State Fair Hearing is made against you, Delaware First Health may recover the cost of the services provided to you while your appeal or State Fair Hearing were pending.

State Fair Hearings

You or your authorized representative have the right to request a State Fair Hearing with the State of Delaware. A State Fair Hearing is a meeting between you, your authorized representative, a hearing officer, and a representative from Delaware First Health.

You can submit evidence, present your case, examine records, and ask questions about your request during the hearing process. You must ask for a State Fair Hearing within 120 calendar days of the appeal decision letter you get from us. You must go through Delaware First Health’s appeal process before asking for a State Fair Hearing. You may request a hearing by calling, emailing or writing to the state’s division of Medicaid and Medical Assistance (DMMA) office.

• In writing to:

Division of Medicaid and Medical Assistance

DMMA State Fair Hearing Officer

1901 North DuPont Highway

PO Box 906, Lewis Building

New Castle, DE 19720

• By fax: 1-302-255-9614
• By Phone: 1-302-255-9500 or toll-free at 1-800-372-2022.

For other languages, call 1-866-843-7212.

• To ask for a fair hearing by email, please send your request to DHSS_DSS_FHRequest@delaware.gov.

State Fair Hearing Process

You or your representative will get a letter from the State Fair Hearing office that will tell you the date, time, and place of the hearing. The hearing can be held in person or by phone. The letter will tell you more information about the hearing process.

You or your representative may review all information regarding the State Fair Hearing. Delaware First Health will also have a representative at the hearing.

In accordance with Federal policy, if the decision of the State Fair Hearing is made against you, Delaware First Health may recover the cost of the services provided to you while your appeal or State Fair Hearing were pending.