Grievances

What is a grievance?

When Keystone First denies, decreases, or approves a service or item different than the service or item you requested because it is not medically necessary, you will get a letter (notice) telling you Keystone First’s decision.

A grievance is when you tell us you disagree with Keystone First’s decision.

What should I do if I have a grievance?

FIRST LEVEL GRIEVANCE
To file a grievance, you can:

  • Call Keystone First at 1-800-521-6860 and tell us your grievance, or
  • Write down your grievance and send it to us at:

Member Appeals Department
Attention: Member Advocate
Keystone First
200 Stevens Drive
Philadelphia, PA 19113-1570, or

  • Your provider can file a grievance for you if you give the provider your consent in writing to do so.

NOTE: If your provider files a grievance for you, you cannot file a separate grievance on your own.

When should I file a first level grievance?

You have 45 days from the date you receive the letter (notice) that tells you about the denial, decrease, or approval of a different service or item to file your grievance.

What happens after I file a first level grievance?

After you file your grievance, you will get a letter from Keystone First telling you that we have received your grievance and about the first level grievance review process.

You may ask Keystone First to see and ask for a copy of any information we have about your grievance. You may also send information to Keystone First that may help with your grievance.

You may attend the grievance review if you want to.  You may come to our offices or be included by phone or by video conference, if available. If you decide that you do not want to attend the grievance review, it will not affect our decision.

A committee of one or more Keystone First staff (including a licensed doctor) who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision.  Your grievance will be decided no later than 30 days after we received your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped and you file a grievance that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are being reduced, changed or stopped, the services or items will continue until a decision is made.

What if I do not like Keystone First’s decision?

SECOND LEVEL GRIEVANCE
If you do not agree with our first level grievance decision, you may file a second level grievance with Keystone First.

When should I file a second level grievance?

You must file your second level grievance within 45 days of the date you receive the first level grievance decision letter. To file a second level grievance, you can:

  • Call Keystone First at 1-888-671-5276 and tell us your second level grievance, or
  • Write down your second level grievance and send it to us at:

Keystone First
Member Appeals Unit
200 Stevens Drive
Philadelphia, PA 19113-1570

What happens after I file a second level grievance?

You will receive a letter from Keystone First telling you that we have received your grievance, and telling you about the second level grievance review process.

You may ask Keystone First to see and ask for a copy of any information we have about your grievance. You may also send information to Keystone First that may help with your grievance.

You may attend the grievance review if you want to. You may come to our offices or be included by phone or by video conference, if available. If you decide that you do not want to attend the grievance review, it will not affect our decision.

A committee of three or more people (including a doctor and at least one person who is not an employee of Keystone First or a related subsidiary or affiliate) who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision. Your grievance will be decided no later than 45 days after we receive your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped and you file a second level grievance that is hand-delivered or postmarked within 10 days of the date on the first level grievance decision letter, the services or items will continue until a decision is made.

What can I do if I still do not like Keystone First’s decision?

EXTERNAL GRIEVANCE REVIEW

If you do not agree with the Keystone First second level grievance decision, you may ask for an external grievance review.

You must call or send a letter to Keystone First asking for an external grievance review within 15 days of the date you received our grievance decision letter. The address is:

Keystone First
Member Appeals Unit
External Grievance Review
P.O. Box 41820
Philadelphia, PA 19101-1820
1-888-671-5276

We will then send your request to the Department of Health. The Department of Health will notify you of the external grievance reviewer’s name, address and phone number. You will also be given information about the external review process.

Keystone First will send your grievance file to the reviewer. You may provide additional information to the reviewer that may help with the external review of your grievance, within 15 days of filing the request for an external grievance review.

You will receive a decision letter within 60 days of the date you asked for an external grievance review.  This letter will tell you the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped and you request an external grievance review that is hand-delivered or postmarked within 10 days of the date on the second level grievance decision letter, the service or items will continue until a decision is made.

You may call Keystone First's toll-free telephone number at 1-800-521-6860; you can contact Legal Aid at 1-800-322-7572; or you can contact the Pennsylvania Health Law Project at 1-800-274-3258 if you need help or have questions about complaints and grievances.

Members