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Step 3: Define complaint reasons

Updated on April 23, 2021

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 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
Rudeness / disrespect by staffGrievance
Health PlanRudeness / disrespect by staffGrievance
Rudeness / disrespect by staffGrievance
Enrolment / disenrollment issueGrievance
Plan Benefit issueGrievance
Pharmacy access issueGrievance
Customer service issueGrievance
CMS issueGrievance
Other issuesGrievance
Process issuesGrievance
Marketing issuesGrievance
Pharmacy access issueGrievance
Customer service issueGrievance

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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