Grievance Process
(also referred to as "Complaint")

What is a Grievance?

As a Care1st Health Plan Member, you have a right to file a complaint (grievance) if you have a problem with your medical care or our services. However, the complaint process is used for only certain types of problems. They include quality of care, waiting times and the customer service you receive.

How to file a Grievance, step-by-step.

Step 1

Contact us promptly

Whether you call or write, be sure to contact Member Services right away.
The complaint must be made within 60 calendar days after you had the problem you want to complain about.

Fast complaints
If you are making a complaint because we denied your request for a 'fast coverage decision' or a 'fast appeal', we will automatically give you a 'fast complaint'.

If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a "fast complaint".

If you have a "fast complaint," it means we will give you an answer within 24 hours.

Legal Terms - A "fast complaint" is also called an "expedited grievance."

Download the Grievance form by clicking on this link: Grievance Form and Instructions

Step 2

We will acknowledge receipt of your grievance

We will acknowledge receipt of your written grievance within five (5) days of receiving it. We will conduct a review of your issues. We may request your medical records as part of our review.

We will mail you a response to your complaint within thirty (30) days of receiving your complaint. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint. We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

For Expedited grievance requests or "fast complaint," we will respond within twenty four (24) hours. We will address your grievance as quickly as your case requires based on your health status.

Step 3

We review your complaint and give you our answer

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call.

Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Step 4

When your complaint is about quality of care, you have one extra option:

  1. You can make your complaint to the Quality Improvement Organization (QIO). This can be done without or in addition to making the complaint to Care1st.

For further information on the Grievance Process, Please refer to your Evidence of Coverage.

Care1st AdvantageOptimum Plan (HMO) and Coordinated Choice Plan (HMO)
Refer to Chapter 9, Sections 1, 2, 3, and 10 of the Evidence of Coverage

Care1st TotalDual Plan (HMO SNP)
Refer to Chapter 9, Section 1, 2, 3, 11 and 12 of the Evidence of Coverage

You can also tell Medicare about your complaint.
To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx or please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions . Please contact Member Services at 1-800-544-0088 (TTY: 711)