Member Information on Grievances

Grievances are written complaints made by a subscriber, dependent, and/or guardian regarding UMBH’s quality of service, quality of care, access or availability, provisions of services, and claims administration. A grievance may also include a complaint related to an adverse determination made pursuant upon utilization review.

• All staff will be educated concerning the importance of the grievance procedure and the rights of the subscriber, dependent, and/or guardian that have submitted the formal complaint.
  • When not delegated contractually, UMBH will coordinate and cooperate fully with the appropriate contracted Health Plan to assist in the resolution of the grievance.
• Administrative and clinical staff will be available to assist or coordinate with contracted Health Plans the grievance procedure.
• All formal grievances may be filed no later than one year from the time of occurrence. The formal grievance must be completed in writing and submitted to UMBH.
• The subscriber, dependent, and/or guardian expressing their dissatisfaction, will receive an acknowledgement letter and a copy of the Grievance Procedures within five (5) working days of UMBH’s receipt.
• All grievances will be documented and tracked for accurate resolution within the required time frames. Grievance documentation may include, but is not limited to:
  • Assessment of UMBH’s responsibilities
  • Background information as it pertains to the formal complaint
  • Discussion(s) with any individual relevant to the formal complaint
• The subscriber, dependent, and/or guardian expressing their dissatisfaction, has the right to receive assistance from any UMBH contracted network provider, administrative or clinical staff during the grievance procedure.
• UMBH will process all formal grievances within a reasonable time not to exceed sixty (60) days; from the initial filing of the formal complaint.
  o If the grievance involves the collection of information outside the service area, UMBH will have an additional thirty days to process the grievance through all grievance levels.
  • The individual petitioning the grievance will be notified in writing regarding the need for the time extension.
  • Upon UMBH’s receipt of the requested information, the time for completion of the formal grievance resumes with resolution and notification completed within 90 days from the initial filing of the grievance.
  • The Grievance Committee will notify the subscriber, dependent, and/or guardian of their findings within seven (7) working days of receiving the requested information with the resolution and notification completed within the 90 days from the initial filing of the grievance.
• If UMBH is unable to resolve the formal grievance to the satisfaction of the member who submitted the formal grievance, UMBH shall notify the subscriber, dependent, and/or guardian of their right to appeal to the Agency for Health Care Administration (AHCA).