Provider Responsibilities During the Complaint Process
Carelon works collaboratively with participating Providers throughout the complaint process. Providers are expected to respond timely to requests for information and support Carelon in completing a thorough review of the concerns presented. Carelon’s complaint process may include review of Provider records, policies, staff statements, and other documentation relevant to the complaint.
When a complaint involving a Provider is filed, Carelon will notify the Provider and issue a written request identifying the information needed for the review. The Provider is expected to:
- Review the complaint and complete an internal investigation;
- Submit a written summary response addressing the concerns;
- Provide the requested records, policies, statements, or other supporting documentation within seven business days;
- Respond to additional questions or requests for clarification from the Complaint Investigator, when needed; and
- Cooperate with any additional review activities necessary to resolve the complaint.
Carelon’s Complaint Investigator may contact the Provider during the investigation to clarify information, request additional records, or discuss concerns identified during the review. The Provider is responsible for responding within the timeframe communicated by Carelon.
Following review by the Complaint Review Committee (CRC), the Provider will receive a copy of the complaint decision notice. If the complainant appeals the First Level Complaint decision, the Provider will be notified of the appeal decision once the review is completed.
Carelon’s Complaint Review Committee (CRC) may identify follow-up recommendations as part of its review of a complaint. Recommendations may be made whether or not the complaint is supported or confirmed and are intended to address identified concerns and support improvement in treatment services and quality of care for our Members. Providers are expected to:
- Respond within the timeframe requested by Carelon;
- Collaborate with Carelon to address identified quality, safety, or process concerns;
- Complete or implement agreed-upon follow-up actions; and
- Provide documentation requested by Carelon to demonstrate completion.
Follow-up may include staff training, policy or procedure updates, documentation improvements, implementation of best practices, additional internal review, or other corrective action. Carelon may work with the Provider to identify an alternative approach when the proposed action adequately addresses the identified quality improvement concern and satisfies the CRC’s request.
Participating Providers are required under their Provider Agreement to cooperate with Carelon’s Quality Improvement Program and related Quality Management activities. The Provider Manual is incorporated into the Provider Agreement, making these requirements part of the Provider’s contractual obligations. As part of that obligation, Providers must cooperate with Carelon in addressing and completing CRC follow-up recommendations. Failure to cooperate with required CRC follow-up may be addressed in accordance with the Provider Agreement, this Provider Manual, and applicable network management processes.
Providers should ensure that Carelon has current contact information for the individual responsible for receiving and coordinating complaint-related communications. Please send any changes to your complaint point of contact to PAMedicaidQM@Carelon.com