Billing Manual for Community Care Network Providers

II.D.3 Providers’ Role in the Preventive Health ProgramProviders play an important role in the success of the Preventive Health Program.Community Care asks providers to make the educational newsletters available in theiroffices and to tell suitable members about the programs. In addition, Community Careasks providers to answer member questions about the educational newsletters and toprovide additional information if requested. Providers are also welcome to contactCommunity Care with suggestions or to learn about future programs.II.E. Member Complaint and Appeal ProceduresCommunity Care’s policy for the resolution of complaints has been developed toestablish an objective review process to investigate and resolve all complaints in anappropriate and timely manner and to meet all county, state, and NCQA requirements.We ensure impartial review by designating reviewers who are not associated with theissue being considered and have not already reviewed the issue.InquiryAn inquiry is defined as any member’s request for administrative services orinformation, or expressing an opinion. Whenever specific corrective action is requestedby the member or determined to be necessary by Community Care, an inquiry isclassified as a complaint.ComplaintA complaint is defined as a dispute or objection by a member or their representative,which may include the member’s provider, with proof of the member’s writtenauthorization for the representative, to be involved and/or take action on the member’sbehalf, regarding a participating health care provider, or the coverage (includingcontract exclusions and non-covered benefits), operations, or management policies ofCommunity Care that has not been resolved by our organization and has been filed withCommunity Care, the Pennsylvania Department of Health, or the PennsylvaniaInsurance Department. The term does not include a grievance.Second Level ComplaintA statement of disagreement, either written or oral, with the resolution of a complaint,which is perceived to be unsatisfactory by the member, which is subject to a secondlevel review within a 30-day timeframe.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 39