Grievance Resolution

Complaint/Grievance Resolution Procedure

It is important to PVCS that members are treated fairly and receive prompt responses to questions and concerns. PVCS asks members who have questions, concerns, or issues with Plan benefits or services, to first contact PVCS Customer Services at 1-888-357-6912 for assistance. Should a member want to submit a grievance, PVCS provides a procedure to promote prompt and responsible resolution to issues raised by Plan members. The process outlined below should be used.

Step One:

Discuss Complaint Directly with PVCS or Provider.
Members should first address the complaint at the source (if at provider office, with office manager or doctor; if Plan benefit, provider, or reimbursement question, call PVCS Customer Services 1-888-357-6912). If the complaint is not resolved as a result of this discussion, or such a discussion is not appropriate under the circumstances, proceed to Step Two.

Step Two:

Prepare and Submit Complaint Procedure Form to PVCS Customer Service for Review.
If the member feels their question or concern was not resolved verbally (Step One), the member may prepare and submit a formal written complaint for review by PVCS. The member should prepare a "Complaint/Grievance" Form and submit it to PVCS Customer Service within seven (7) business days of the Step One discussion (or within seven (7) days of the event, if Step One is bypassed). Customer Service will review the complaint; contact appropriate individuals (member, provider and /or PVCS staff) for additional information, if needed; review all the information gathered on the complaint, and then make a decision/resolution regarding the complaint. The decision/resolution will be reviewed and approved by the PVCS Medical Director. The final written response will be sent to the member, generally within fourteen working days or sooner.
General Information
The time limits above are subject to modification on a case-by-case basis due to operational requirements, in-depth investigations, etc. The Medical Director shall have final authority to resolve any disputes regarding the implementation of this Complaint Procedure, including determination of the appropriate action.