Grievance and Appeal Information

Every participant is encouraged to voice grievances and complaints. Participants, their family members or representatives are provided the opportunity to voice complaints without discrimination or reprisal and with swift response from the administrative team. Grievances are not limited to formal written processes. Participants, their family members or representatives can also verbalize a complaint to program staff or may raise concerns during meetings such as Participant Council, Interdisciplinary Care Plan meeting, Participant Orientation, etc. In all cases, staff will follow-up on complaints voiced by participants, their family members or representatives.

 

Grievance/appeal forms and procedures shall be made available to participants, their family members or representatives at denial of enrollment, enrollment, annually and upon denial of payment or coverage of a service. Albright LIFE will ask participants, their family members or representatives about any special communications needs, and make assessment of any special communication needs each time forms and procedure are made available.

Grievance Procedure:

A grievance is a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished. A grievance is not limited to a formal written process. A participant, their family members or representatives may verbalize a complaint to any program staff. Participants, their family members or representatives may raise concerns during meetings such as Participant Council, interdisciplinary staff meetings or participant orientation.

The staff member or contractor hearing the concern will meet with you and fill out a Participant Concern/Grievance Form. These forms are available at the LIFE Center, or click here to download a copy of the form. Or you may call the Albright LIFE Center directly.

If assistance in filing a grievance/appeal is necessary or requested by participants, their family members or representatives, Albright LIFE must immediately notify the local Area Agency on Aging (AAA) office and jointly cooperate with them in assisting the participant, their family members or representatives in the process.

• You will be provided in writing the steps and timeframe for our response to your grievance.
• Grievances will be held in confidence and there will be no discrimination against you due to filing a grievance/appeal.
• After your appeal is received by Albright LIFE, you will continue to receive all services during the appeal process.
• The staff recording your grievance will report it to the interdisciplinary team within 5 working days.
• If within 5 days since the grievance was reported to the IDT, you agree with the outcome, the form will be completed and the grievance will be considered resolved.
• If you do not agree to the outcome, a written report will be sent to the Executive Director (or if the grievance involves clinical care to the Medical Director) for final review and action within 5 working days.
• After this review but within 5 working days, a copy of the written report will be sent to you.
• If you still do not agree with the outcome, you have 30 days to submit a request in writing for a review by the Albright LIFE Plan Advisory Committee.
• The Plan Advisory Committee will send you written acknowledgment of receipt of the grievance within 5 working days. The committee will then investigate, find a solution and take appropriate actions.
• The committee has 30 working days from the date the grievance is filed with the committee to send you a completed report containing a description of the grievance, the actions taken to resolve the grievance and the basis for such action.
• If you do not agree with the results of the committee review, a copy of the report will be sent immediately to CMS, PA DHS, and the ombudsman.

Appeal Procedure:

It is Albright LIFE’s policy to assure that all participants, their family members or representatives as well as contractors are made aware of their right to appeal. An appeal is a participant’s, family members” or representative’s or contractor’s action taken on behalf of a participant with respect to:

• Non-coverage or non-payment of a service
• Denial of a service request
• Reduction, termination or suspension of a service
• Untimely provision of services
• Denial of enrollment
• Involuntary disenrollment

You will be provided with a notice on how to appeal the decision if you do not agree with our outcome.

• You must request an appeal either orally or in writing within 30 calendar days of our denial of service notice to you. Albright LIFE will confirm in writing the receipt of the appeal within 24 hours of receipt of the appeal request. We will continue to furnish the disputed service until the final determination is made if we are proposing to terminate or reduce services currently being provided and if you agree that you will be liable for the cost of the disputed services if the appeal is not resolved in your favor.
• An impartial third party will review your appeal and you will receive reasonable written advance notice of the third party review so that you have the opportunity to present evidence related to the dispute.
• You will receive an Appeal Resolution letter no later than 30 days after your appeal is filed. If the decision is made in your favor, we will provide or pay for the disputed service immediately.
• If you do not agree with the decision, the report will be forwarded to CMS, PA DHS and the ombudsman. You will also receive notice of additional appeal rights through Medicare and Medicaid. Our staff will assist you in choosing which agency to appeal to and help you submit the appropriate paperwork.
• If you feel that not receiving the service in dispute would seriously jeopardize your life, health or ability to regain maximum function, you can request an expedited appeal either orally or in writing. Albright LIFE will respond to a request to an expedited appeal no later than 72 hours after receipt of the appeal.