What’s the difference between a grievance and an appeal?
Complaints about healthcare coverage or quality of care fall into one of two categories: • A grievance is a written complaint submitted by a member (or on the member’s behalf) about the quality of services PacificSource offers. This can include issues such as the availability, delivery, or quality of healthcare services; utilization review decisions; or claims payment, handling, or reimbursement for services. You should file a grievance if you believe that medically necessary care that is covered by your health plan has been denied, reduced, or ended unduly and you want to receive care. • An appeal is a written request submitted by a member (or on the member’s behalf) requesting reconsideration of a previous decision we made in the grievance and appeals process.
