Grievances Policies and Processes

We hope our health plan serves you well. If you are unhappy or have a complaint, you may talk with your primary care provider, and you may call Member and Recipient Services at 800-510-9132 or write to us.

A grievance and a complaint are the same things. Contacting us with a grievance means that you are unhappy with your health plan, your provider, or your health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your problem, and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.

You can ask a family member, a friend, your provider, or a legal representative to help you with your complaint. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out any forms, we can help you.

You can contact us by phone or in writing:

• PHONE: Call Member and Recipient Services Monday through Saturday, 7 a.m. to 6 p.m at 800-510-9132. After these hours you may leave a message and we will contact you during the next business day.
• MAIL: You can write us with your complaint to
  Alliance Health
  Quality Management Department
  Attn: Complaints and Grievances
  5200 W. Paramount Parkway, Suite 200
  Morrisville, NC 27560
• EMAIL: [email protected]

When grievances are received, we ensure that the person or people addressing the grievance have not been involved in any previous level of decision-making related to the grievance. Grievances involving medical care are reviewed by Alliance Health Clinical Quality Review (CQR) committee. If there is reasonable cause to believe that an adult with a disability, a child, or an adolescent may be abused, neglected or exploited, Alliance Health will contact the Department of Social Services (DSS).

We will let you know in writing that we got your complaint within 5 days of receiving it.

We will initially attempt to resolve the issue through informal discussions to reach an agreement. We will not try to influence, limit, or interfere with your rights or decisions about a grievance. As part of the resolution process, we may:

• Offer a member alternative services
• Engage you and/or your provider in educational or clinical discussions
• Engage in informal attempts to resolve the issues

We will review your complaint and tell you how we resolved it in writing within 30 days of receiving your complaint.

If your grievance is about your request for an expedited (faster) appeal, we will tell you how we resolved it in writing within 5 days of getting your complaint. If you are not satisfied with the resolution of your grievance, you can file an appeal with Alliance’s Chief Executive Officer (CEO) within 21 days of receiving your resolution letter. A decision about the appeal will be provided within 20 working days along with further appeal rights that may be available.

You may also contact the Department’s Customer Service and Community Rights team at 984-236-5300 or toll-free at 855-262-1946 if you are not satisfied with the resolution of your grievance.

All grievances are processed in compliance with Alliance procedure #6503: Management and Investigations of Grievances.