Kathleen G. Kane - Pennsylvania Office of Attorney General - Protecting Pennsylvanians

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YOUR RIGHTS UNDER ACT 68

If your health plan is a "managed care plan", you may have certain rights under Act 68.

Please Read Carefully:

Filing a complaint with the Attorney General may not preserve your appeal rights, pursuant to ACT 68. To preserve your rights, you must file a complaint or grievance appeal directly with your health plan or in conformance with the terms of your coverage. The Office of Attorney General does not give legal advice.

If you have a problem with your HMO or Point of Service plan, you should"Take the Proper Steps", as follows:

1. Call your managed care plan member services department. Always call your managed care plan member services department first. Give them a chance to solve the problem. Many problems are solved at this level in an informal manner.


2. File a complaint or grievance with your plan. If your phone call to the plan does not solve your problem, call the plan again and tell them that you want to file either a first-level complaint or grievance.


3. About the internal complaint & grievance process time frames.  This first-level internal process will be completed within 30 days of receipt of your complaint or grievance and you will be notified within 5 business days. Notice will include the basis for the decision and the procedure to file a second-level internal review. You have a right to appear before the second-level review committee.  Second-level  reviews must be completed within 45 days and written notification of the committee's decision must be provided within five (5) business days of the decision.

4. File an appeal. Separate external appeals for complaints and grievances exist. Complaint appeals go to either the Department of Health or Insurance. Grievance appeals go to the plan. The plan will notify the Department of Health who will then assign an independent certified utilization review entity. The review is decided on the basis of whether or not the health service is medically necessary and appropriate. The plan may impose a $25.00 filing fee. Grievance or complaint appeals must be made within 15 days of denial of the second-level review decision.

Grievance - for example, denial of payment for a health care service.

Complaint - for example, a problem with a provider or the coverage operations or management policies of the health plan only.

Please note: There may be different procedures for handling complaints and grievances for the following:

1. A federal employee or dependent enrolled in a managed care plan;

2. Medicare or Medicaid recipient enrolled in a managed care plan; and

3. Employed by an ERISA funded business.