File a Grievance or Appeal
HOW TO FILE A GRIEVANCE
A grievance is a complaint, either oral or written, that expresses dissatisfaction with the quality of care, services, or treatment you receive. A Participant, Participants family member, designated representative or caregiver may file a grievance at any time by speaking with any LIFE Pittsburgh staff member or contractor, who can help submit the grievance on your behalf. You may also file a grievance by calling 412-388-8040 and asking to speak with the Director of Quality and Compliance, or by submitting your concern in writing via email to Quality Assurance at Quality@lifepittsburgh.org. Assistance is available to help you file a grievance, including language services and accommodation for hearing, vision, or other needs.
All grievances are handled promptly, reviewed by the appropriate team, the Quality Department and will be kept confidential. Filing a grievance will not affect your services, care, or treatment in any way, and you will not be treated differently for raising a concern. You will be notified of the outcome of the review. If you are not satisfied with the resolution, you have the right to submit a written appeal within 30 days of receiving the decision for review by LIFE Pittsburgh’s Plan Advisory Committee. You may also file a complaint with external agencies at any time without first filing a grievance with LIFE Pittsburgh.
HOW TO FILE AN APPEAL
An appeal is a Participant’s action taken with respect to LIFE Pittsburgh’s noncoverage of, or nonpayment for, a service including denials, reductions, or termination of services. A request to initiate, modify or continue a service must first be processed as a service determination request before LIFE Pittsburgh can process an appeal. You will be notified in writing if LIFE Pittsburgh will not cover or pay for a service that you are receiving or requesting; are denied enrollment into LIFE Pittsburgh; or are involuntarily disenrolled from LIFE Pittsburgh. The notice will instruct you how to appeal the decision if you are not in agreement. You must request an appeal within 30 days of LIFE Pittsburgh’s notice. You may file an appeal either verbally, in person or by telephone, or in writing, with LIFE Pittsburgh staff.
If you wish to file an appeal by telephone, you may contact: Director of Quality and Compliance at 412-388-8040 Ext 6326
If you wish to file an appeal in writing, please send your written appeal to: Director of Quality and Compliance LIFE Pittsburgh 875 Greentree Rd, One Parkway Center, Suite 200 Pittsburgh, PA 15220
Assistance is available to help you file an appeal, including language services and accommodation for hearing, vision, or other needs.
If you believe your life, health or ability to regain or maintain maximum function (get well or stay well) will be in danger if you do not receive the service in question, you can request that LIFE Pittsburgh speed up the appeal process. This is called an expedited appeal. LIFE Pittsburgh will automatically decide on your expedited appeal as quickly as your health requires, but no later than 72 hours after receiving your request for an expedited appeal. This time frame may be extended by up to 14 calendar days if you ask for the extension, or if LIFE justifies, to the State Administering Agency, the need for more information and how the delay benefits you.
For standard appeals (those that are not expedited), LIFE Pittsburgh will provide a written response to your appeal as quickly as your health requires, but no later than 30 calendar days after receiving your appeal.
In accordance with federal PACE regulations (42 CFR §460.122 and §460.124), if LIFE Pittsburgh upholds a decision that is not fully in your favor, your appeal will be automatically and timely submitted to an independent third-party review entity for further consideration. This review is conducted by individuals who are not involved in the original decision and ensures an impartial evaluation of your case. Additionally, if you request an appeal in a timely manner for the reduction, suspension, or termination of a previously authorized service, those services will continue without interruption until the appeal process is completed, as required under federal regulations.
If the independent third-party review entity makes a decision that is not fully in your favor, you have additional appeal rights called external appeal rights. An external appeal involves a new and impartial review of your case through either the Medicare or the Medicaid Managed Care program. If you are enrolled in both Medicare and Medicaid Managed Care, you may choose which appeal process you wish to use. If you are not sure which program applies to you, please ask. LIFE Pittsburgh can explain how the processes differ, and whether one would be more appropriate. The external appeal may only be made to one or the other (Medicare or Medicaid Managed Care), but not both.