Creating a Grievance
Overview
A grievance is a complaint or dispute expressing dissatisfaction with the manner in which a Health Plan or a delegated entity provides health care services, regardless of whether any remedial action can be taken. They include concerns about the quality or timeliness of the care that was received.
In the application, grievances are the formal process by which health plan members or providers can communicate complaints and seek remedies from the health plan.
* Access to Utilization Management * Permission to submit and/or review a grievance * Permission to create, view, link and/or delete attachments
When you need to create a grievance for provider conduct or quality of care that may or may not be related to a request.
* You can select associated requests created for the same member within 90 days for grievance request. * Multiple requests can be linked to a grievance. * Grievance requests cannot be associated with another grievance request. * A grievance can be created from the **Fax** tab on the UM Worklist if you have Fax permissions. The workflow is the same as from the Request tab.
Starting Point
If your starting point is the UM Worklist, select New Request > Grievance.
Recommended- starting point is the CPV. Select New Request > Grievance.
Creating a Grievance Request
Enter the information in the **Create Grievance Request** window.
**Requester Information*** **Required:** * Request Source: Defaults to **Phone** * Optional: * Requester Name * Requester Type * Contact Phone * Contact Email * Fax**Request Details:** Selections are based on your organization's configurations.* **Required:** * Classification- defaults to **Grievance** * Treatment Setting * Urgency * Notification Date/Time - Defaults to current; can be modified * **Optional:** * Claim Number
Click **Create**.
_(Alternate)_ Click Cancel to cancel the grievance request.
New Request Basic Information
On the New Request page, the information you just entered is populated into the request details. If you need to modify any of the detailed information, click the pencil
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Person Information
If you created the grievance from the CPV, the Person Information is populated.To change enrollments, choose a different enrollment from the table.
If you started from the worklist, you can either **search** for the person associated to the grievance or **Add a Temporary Person**.
Provider Information
If the Grievance is about the provider, select **Yes**, and then search for the provider. The system defaults to No.
All the Provider Search options are available to choose from, or you can **Add a Temporary Provider**.
You can add multiple providers to a grievance.
Provider Role is optional on a grievance.
To remove a provider, click the  trash can icon.
If the grievance is about the provider, you must add a provider before continuing, or you will receive an error message.
Click **Continue**._(Alternate)_ Click Delete Draft.
Custom Fields
If your organization utilizes request custom fields, enter the information on the Custom Fields screen.
Click **Continue**._(Alternate)_ Click Delete Draft.
Service Information
Grievance
A intake questionnaire displays in the Grievance section. Click **Complete Questionnaire**._(Optional)_ If the questionnaire is not completed during intake, it can be completed later.
Complete the questionnaire, and then click **Save** when complete.
If any information was entered in the questionnaire prior to clicking Cancel, those responses **will be maintained.**
_(Alternate)_ Click Cancel to return to the Grievance section.
Duration
This is the turnaround time (TAT) for the grievance. Follow your organization’s policies for setting the duration. The From date can be modified, the Through date will automatically calculate based on the from date and duration and cannot be modified.
If needed, update the duration number, units and from date.
Grievance Details
In the Grievance Details, the system defaults to No, the grievance is not related to a previous request for healthcare services.
Select **Yes** if the grievance is related to a previous request. Otherwise, click **Continue** if the grievance is not related to a previous request.
Available requests are displayed. Select the request(s) by clicking the check box before the request ID.
If you selected Yes but there are no available requests, a message displays.
If you selected Yes but did not choose a request, an error message displays.
Click **Continue**._(Alternate)_ Click Delete Draft.
Additional Information
Attachments
Attachments can be added to the grievance via upload or drag and drop.
File type requirements-.mp3, .mp4, .jpeg, .jpg, .png, .gif, .bmp, .tiff, .svg, .doc, .docx, .pdf, .xlsx, .txt, .img files at 1024mb or less.
An error message displays if the file type does not match the requirements.
Error for Link
Error for File
Choose which method you will use to attach your artifact.
After adding the attachment, the following fields are _**Optional**_ for updates:* **File Title:** Defaults to the file name but can be modified. * **Category:** Selections available are based on your organization's configurations. * **Association:** Initial request defaults.
After adding the attachments, you can download, edit, or delete them.
Click **Continue**._(Alternate)_ Delete Draft.
Review and Submit
In this section, you can review and make any necessary edits.
Edits can be done by clicking the **pencil**  icon on the line you need to modify.
Alternatively, you can navigate back to the section using the menu on the left panel. Click the section you want to modify.
After completing you updates, click **Submit**. The request submitted screen displays details of the new grievance request._(Alternate)_ Delete Draft.
Click either **Back to CPV** or **View Request**.
* If you select View Request, the request displays. The request is set to **Pended** status. * The User owner is the person opening the grievance request. * Department owner may or may not be set on the requested based on your organization's workflow configuration.
* If you select Return to CPV, the Request tab displays.
Click anywhere on the Grievance request to view the details.