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Complaints, Grievances and Appeals

COMPLAINTS

If your complaint is about a service you or a provider feels you need but we will not cover, you can ask us to review your request again. This is called an appeal.

If your complaint is about something other than not receiving a service, this is called a grievance. Examples of grievances would be not being able to find a doctor, trouble getting an appointment or not being treated fairly by someone who works at MPC or at your doctor’s office.

If you have a complaint you can contact us at 1-800-953-8854 or TTY/TDD at 1-800-735-2258.

GRIEVANCES

If your complaint is about something other than not receiving a service, this is called a grievance. Examples of grievances would be not being able to find a doctor, trouble getting an appointment or not being treated fairly by someone who works at MPC or at your doctor’s office.

If your grievance is:

  • About an urgent medical problem you are having, it will be solved within 24 hours.
  • About a medical problem but it is not urgent, it will be solved within five days.
  • Not about a medical problem, it will be solved within 30 days.

If you would like a copy of our official complaint procedure or if you need help filing a complaint, please call the MPC’s Member Services Department at 1‑800‑953‑8854.

APPEALS

To file, members may call 1-800-953-8854 or complete the Members Appeal form. MPC can also mail or fax the appeal form to you and assist in completing the form.

Once complete, you may fax the form to 1-866-831-0790 or mail it to:

Maryland Physicians Care, MCO
Attn: Grievance and Appeals Unit
PO Box 893
Portland, ME 04104.

Your doctor can also file an appeal for you if you sign a form giving him or her permission. Other people can also help you file an appeal, like a family member or a lawyer.

When you file an appeal, be sure to let us know any new information that you have that will help us make our decision. We will send you a letter letting you know that we received your appeal within 5 business days. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make our decision.

What Happens During the Review Process

When reviewing your appeal we will:

  • Use doctors who know about the type of illness you have
  • Not use the same people who denied your request for a service
  • Make a decision about your appeal within 30 days

Appeals Timeline

The appeal process may take up to 44 days if you ask for more time to submit information or we need to get additional information from other sources. We will send you a letter if we need additional information.

If your doctor or MPC feels that your appeal should be reviewed quickly due to the seriousness of your condition, you will receive a decision about your appeal within three business days.

If we do not feel that your appeal needs to be reviewed quickly, we will try to call you and send you a letter letting you know that your appeal will be reviewed within 30 days.

If your appeal is about a service that was already authorized and you were already receiving, you may be able to keep getting the service while we review your appeal. Contact us at 1‑800‑953‑8854 if you would like to keep getting services while your appeal is reviewed. If you do not win your appeal, you may have to pay for the services that you received while the appeal was being reviewed.

Appeals Decisions

Once we complete our review, we will send you a letter letting you know our decision. If we decide that you should not receive the denied service, that letter will tell you how to file another appeal or ask for a State Fair Hearing.

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