CountyCare - Provider Complaints, Provider Disputes, Member Grievances, and Member Appeals

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Provider Complaints, Provider Disputes, Member Grievances, and Member Appeals

CountyCare has established a system to allow members and providers to bring issues of concern to our attention. See below for additional information on provider complaints, member grievances and member appeals.

Provider Complaints

CountyCare has established a provider complaint system that allows a provider to dispute the policies, procedures, or any aspect of the administrative function. We take all complaints very seriously. We view complaints as an opportunity to improve the service we provide to our provider partners. CountyCare has designated a Provider Complaints Coordinator (PCC) to process provider complaints. Provider complaints will be thoroughly investigated. The PCC will provide a written notice of resolution to the provider within thirty days from the date of the decision.

Provider Complaints may be submitted in writing to:

CountyCare Health Plan
P.O. Box 21153
Eagan, MN 55121

Or you can call Provider Services at 312-864-8200 / 855-444-1661 / 711 TTD/TTY.

Provider Disputes

Providers have the right to submit a dispute to decisions made by CountyCare.  Providers may submit a dispute through the new CountyCare Provider Dispute System. Provider disputes may be submitted for any of the following reasons: payment/claims, contracting, eligibility, prior authorization, provider enrollment or system issue. All requests for disputes must be received within 60 calendar days from the date of the Explanation of Payment (EOP) or Remittance Notice. Once all necessary information has been received from the provider, all dispute types will be researched and responded to in no more than 30 business days from receipt of the dispute, with either a confirmed and completed resolution OR a substantive response detailing actions and timeframe to resolve the dispute. The Provider Dispute System User Guide is available for instructions on how to register and submit a Provider Dispute.

Member Grievances

A member grievance is a complaint about any matter impacting a member other than a denied, reduced, or terminated service or item. The grievance process allows the member, or the member’s appointed representative (guardian, caretaker, relative, PCP or other treating physician) acting on behalf of the member, to file a grievance either verbally or in writing. CountyCare values its providers and will not take adverse action against providers who file a grievance on a member’s behalf. For additional information on how to file a grievance on behalf of a member, please see the Provider Manual.

Member Appeals

An appeal is the request for review of a denial or limited authorization of a requested service for a member. The appeals process allows the member, or the member’s appointed representative (guardian, caretaker, relative, PCP or other treating physician) acting on behalf of the member, to file an appeal either verbally or in writing. All appeals must be registered initially with CountyCare and may be appealed to the Department of Healthcare and Family Services when CountyCare’s process has been exhausted. CountyCare values its providers and will not take adverse action against providers who file an appeal on a member’s behalf. For additional information on how to file an appeal behalf of a member, please see the Provider Manual.


  

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