Define complaint reasons
You can select the type(s) of complaint and the reason(s) for the complaint during the complaint intake or creation process.
Based on the complaint type selected, the system displays corresponding reason options based on the data table that stores the complaint type – reason combinations. The selected combination also determines whether the complaint sub-case is an appeal or a grievance or an organization determination. As you can select more than one complaint type during a request, the system can create more than one appeal and/or grievance and/or organization determination subcase.
- The complaint type of Health Plan has the following pre-configured reasons:
- The complaint type of Payment Copayment has the following pre-configured reasons:
- The complaint type of Provider has the following pre-configured reasons:
The complaint type of Treatment/Procedure has the following pre-configured reasons:
The Complaint Type – Reason combinations are stored in a data table of class PegaHC-AG- Data-ComplaintReason that you can extend based on your business needs. Based on the Complaint Type and Reason selected, the system automatically creates Grievance and/or Appeal and/or OD sub-cases to the parent Complaint case. There can be more than one grievance and/or appeal cases and/or OD created as part of one complaint.
| Complaint category | Complaint reason | Appeal or grievance |
| Payment/Copayment | General dissatisfaction | Grievance |
| Amount different than last year | Grievance | |
| Change in premium | Grievance | |
| Plan responsibility | Appeal | |
| Type of service not correct or not at right level | Appeal | |
| Discontinued Service | Appeal | |
| Timing of plan payment | Appeal | |
| Should be a covered service and plan responsibility | Appeal | |
| Treatment/Procedure | Notification of termination of service | Appeal |
| Notification of denial of service | Appeal | |
| Reduction of previously approved service | Appeal | |
| Refusal to authorize service | Appeal | |
| Request for payment | OD (Determination) | |
| Request for service | OD (Determination) | |
| Provider | Current provider no longer contracted | Appeal |
| Timeliness of service | Grievance | |
| Quality of Service | Grievance | |
| Rudeness / disrespect by staff | Grievance | |
| Health Plan | Rudeness / disrespect by staff | Grievance |
| Rudeness / disrespect by staff | Grievance | |
| Enrolment / disenrollment issue | Grievance | |
| Plan Benefit issue | Grievance | |
| Pharmacy access issue | Grievance | |
| Customer service issue | Grievance | |
| CMS issue | Grievance | |
| Other issues | Grievance | |
| Process issues | Grievance | |
| Marketing issues | Grievance | |
| Pharmacy access issue | Grievance | |
| Customer service issue | Grievance | |
| Prescription drug | Request Non-Formulary Exception - Drug not on plan | OD (Determination) |
| Request Non-Formulary Exception - Drug no longer offered on plan | OD (Determination) | |
| Request Formulary Exception - Step therapy exception | OD (Determination) | |
| Request Formulary Exception - Request higher dosage or quantity than limit | OD (Determination) | |
| Request Tiering Exception - Drug in higher cost-share tier | OD (Determination) | |
| Request Tiering Exception - Drug moved to higher cost-share tier | OD (Determination) | |
| Request prior authorization for prescribed drug | OD (Determination) | |
| Request out-of-pocket expense reimbursement for covered drug | OD (Determination) | |
| Charged copay higher than plan limit for a drug | OD (Determination) |
Use the Complaint Reason planning worksheet in the AGM Implementation Planning Workbook to record the desired modifications to the list defined above as needed by the application.
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