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Complaint - Use-case (UC) 1: Create complaint

Updated on January 31, 2022

This functionality performs a search of selected code sets type using specific search criteria (as code only) and displays the results.

Pega Foundation for Healthcare

To create a complaint, complete the following steps:

  1. Log in to the Appeals and Grievance (A&G) User Portal using administrator credentials. The system displays the user dashboard with all cases assigned to the user.

  2. Click New on dashboard and click New Complaint to create a new complaint.
  3. Select Member as the Request source from the following options:
    • Authorized Representative
    • Member
    • Other Entity
    • Provider
  4. Select the appropriate Contact Channel from the following options:
    • Broker
    • Compliance Line
    • CTM (Complaints tracking module)
    • DOI (Department of Insurance)
    • Email
    • Fax
    • Mail
    • Phone
    • Social Media
    • Web Self-Service
  5. Enter or select a date on which the case is created.
  6. Enter or select a date on which the case was received by the organization.
  7. Select the Urgency and Service Type.
  8. Click Continue at the bottom right of screen.

  9. Select Member ID to auto-populate member information. The system allows user to search by selecting a member from the drop-down, or by entering Member ID number, first name, or last name. Note the system only allows selection of a single member record.
  10. Select Plan ID. The system only allows selecting one of the plans in the system.

    The system displays the following plan details:

    • Plan ID
    • Plan Name
    • Effective Date
    • End Date
    • Plan Type
    • Contract ID
    • Line of Business

      Medicare plan type (displayed when member’s Plan ID Line of Business is Medicare)

  11. Verify Member details and then click Continue.

  12. Click Add reason to add category of complaint and the reason for complaint.

    System displays following four categories and associated reasons:

    • Health Plan
    • Payment/Copayment
    • Provider
    • Treatment Procedure
    • Prescription Drug
  13. Select one of the Complaint categories and one associated reason.
    • If the complaint category is Health Plan, the system gives option to capture Contact Name, Contact Phone, and Incident Date.
    • If the complaint category is Treatment procedure, the system gives option to capture Submission type, Type of Service, Place of Service, Service Date, Name of Service Provider, Type of Service Provider, and Prior Authorization Number. Based on the value selected for submission type, system gives option to capture either Claim ID or Authorization ID.
    • If the complaint category is Provider, the system gives option to capture Contact Name, Contact Phone, and Incident Date.
    • If complaint category is Payment/Copayment and the complaint reason is one of the following, the system gives option to capture Claim ID and Authorization ID:
      • Discontinued Service
      • Plan Responsibility
      • Should be a covered service and plan Responsibility (this is single complaint reason)
      • If the Medicare plan type is Medicare Part D and complaint category is Prescription drug, for any selected complaint reason the system gives option to capture Claim ID or Authorization ID based on the ‘Submission type’ value selected and also an option to capture whether the member is residing in long term care facility and prescribing provider’s information.

  14. Enter comments in Complaint justification to capture more details about complaint.

  15. System indicates child case type based on complaint category and reason. Possible child case types are: Appeals, Grievance and Organization Determination (OD).
  16. System provides an option to capture Good cause reason to articulate why a complaint that has been filed outside of the allowable limit is being considered.
  17. Click Submit to create child cases and forward the complaint for processing further.
  18. If required, click Add Reason to add more than one complaint. Repeat steps 11 to 17.

  19. Click Submit at the right bottom of Complaint screen.

The system generates an appeal, determination, or a grievance subcase based on Complaint Category and Complaint reason as per table below:

Complaint categoryComplaint reasonAppeal or grievance
Payment/CopaymentGeneral dissatisfactionGrievance
Amount different than last yearGrievance
Change in premiumGrievance
Plan responsibilityAppeal
Type of service not correct or not at right levelAppeal
Discontinued ServiceAppeal
Timing of plan paymentAppeal
Should be a covered service and plan responsibilityAppeal
Treatment/ProcedureNotification of termination of serviceAppeal
Notification of denial of serviceAppeal
Reduction of previously approved serviceAppeal
Refusal to authorize serviceAppeal
Request for paymentOD (Determination)
Request for serviceOD(Determination)
ProviderCurrent provider no longer contractedAppeal
Timeliness of serviceGrievance
Quality of ServiceGrievance
Health PlanRudeness / disrespect by staffGrievance
Enrolment / disenrollment issueGrievance
Plan Benefit issueGrievance
Pharmacy access issueGrievance
Customer service issueGrievance
CMS issueGrievance
Other issuesGrievance
Process issuesGrievance
Marketing issuesGrievance
Prescription drugRequest Non-Formulary Exception - Drug not on planOD (Determination)
Request Non-Formulary Exception - Drug no longer offered on planOD (Determination)
Request Formulary Exception - Step therapy exceptionOD (Determination)
Request Formulary Exception - Request higher dosage or quantity than limitOD (Determination)
Request Tiering Exception - Drug in higher cost-share tierOD (Determination)
Request Tiering Exception - Drug moved to higher cost-share tierOD (Determination)
Request prior authorization for prescribed drugOD (Determination)
Request out-of-pocket expense reimbursement for covered drugOD (Determination)
Charged copay higher than plan limit for a drugOD (Determination)

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