Grievance and Appeal Information and Instructions

Every participant is encouraged to voice grievances and complaints. Participants/representatives are provided the opportunity to voice complaints without discrimination or reprisal and with swift response from the administrative team.

  • Phone number for oral requests: (717) 381-4321
  • Mailing Address for written requests: 417 West Frederick Street, Lancaster, PA 17603
  • Fax number: (717)  381-4380
  • Executive Director Email: Pamela.Kennedy@AlbrightCare.org

Grievance Procedure:

  • A grievance is a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished. A grievance is not limited to a formal written process. A participant/representative may verbalize a complaint to any program staff. Participants/representative may raise concerns during meetings such as Participant Council, interdisciplinary staff meetings or participant orientation.
  • The staff member or contractor hearing the concern will meet with you and fill out a Participant Concern Form.
  • You will be provided in writing the steps and timeframe for our response to your grievance.
  • Grievances will be held in confidence and there will be no discrimination against you due to filing a grievance/appeal. Albright LIFE will continue to furnish all required services to you during the grievance process.
  • The staff recording your grievance will report it to the interdisciplinary team within 5 working days.
  • If within 5 days since the grievance was filed, you agree with the outcome, the form will be completed and the grievance will be considered resolved.
  • If you do not agree to the outcome, a written report will be sent to the Executive Director (or if the grievance involves clinical care to the Medical Director) for final review and action within 5 working days.
  • After this review but within 5 working days, a copy of the written report will be sent to you.
  • If you still do not agree with the outcome, you have 30 days to submit a request in writing for a review by the Albright LIFE Plan Advisory Committee.
  • The Plan Advisory Committee will send you written acknowledgment of receipt of the grievance within 5 working days. The committee will then investigate, find a solution and take appropriate actions.
  • The committee has 30 working days from the date the grievance is filed with the committee to send you a completed report containing a description of the grievance, the actions taken to resolve the grievance and the basis for such action.
  • If you do not agree with the results of the committee review, a copy of the report will be sent immediately to CMS, PA DHS, and the ombudsman.

Appeal Procedure:

  • It is Albright LIFE’s policy to assure that all participants and contractors are made aware of their right to appeal. An appeal is a participant’s or contractor’s action taken on behalf of a participant with respect to:
  • Non-coverage or non-payment of a service
  • Denial of a service request
  • Reduction, termination or suspension of a service
  • Untimely provision of services
  • Denial of enrollment
  • Involuntary disenrollment

You will be provided with a notice on how to appeal the decision if you do not agree with our outcome.

  • You must request an appeal either orally or in writing within 30 calendar days of our denial of service notice to you.
  • Albright LIFE will confirm in writing the receipt of the appeal within 24 hours of receipt of the appeal request.
  • We will continue to furnish the disputed service until the final determination is made if we are proposing to terminate or reduce services currently being provided and if you agree that you will be liable for the cost of the disputed services if the appeal is not resolved in your favor.
  • An impartial third party will review your appeal and you will receive reasonable written advance notice of the third party review so that you have the opportunity to present evidence related to the dispute.
  • You will receive an Appeal Resolution letter no later than 30 days after your appeal is filed. If the decision is made in your favor, we will provide or pay for the disputed service immediately.
  • If you do not agree with the decision, the report will be forwarded to CMS, PA DHS and the ombudsman. You will also receive notice of additional appeal rights through Medicare and Medicaid. Our staff will assist you in choosing which agency to appeal to and help you submit the appropriate paperwork.
  • If you feel that not receiving the service in dispute would seriously jeopardize your life, health or ability to regain maximum function, you can request an expedited appeal either orally or in writing. Albright LIFE will respond to a request to an expedited appeal no later than 72 hours after receipt of the appeal.

Last updated on September 9th, 2020 at 05:28 pm