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Appeals and Grievances

 

Appeals


You may not agree with a decision or an action made by the plan about its services. For example, you may disagree if we do not cover a treatment or service. In such cases, you may appeal within 30 days of when he or she gets notice of the decision.  Your request should be made in writing. An exception is when your situation needs an urgent decision. Someone you appoint may ask for an appeal for you. This could be your PCP or guardian.
 

Non-Urgent Situation
If your situation is NOT urgent, submit a written request for an appeal to:

Member Services Department
Harmony Health Plan of Illinois, Inc.
P.O. Box 31368
Tampa, FL 33631-3368


 

  • We will let you know what information we need to work on your appeal.
  • We will make a decision within 15 business days of getting the information. We will tell you and your provider orally and in writing of the decision.

Urgent Situation
Call Member Services in an URGENT situation.  The number is 1-800-608-8158. The TTY number is 1-877-650-0952. Ask for an urgent appeal.

  • Harmony will let you know within 24 hours if we need more information.
  • Harmony will make a decision within 24 hours after getting all the needed information. We will notify you and the provider orally and in writing of the decision.

External Independent Review

If your appeal is denied, you can ask for a review.  This review would be done by people outside of the Harmony Health Plan. You have the right to help select the organization that would perform the review.


Grievances

 


You have the right to complain to the plan about your doctor or anything about Harmony Health Plan. You can make your complaint on the phone, in person or in writing. You can also complain if you think you have been treated badly or discriminated against in any way.

Please call Harmony’s Member Services department at 1-800-608-8158 (TTY 1-877-650-0952) to express your complaint, or write to:

Member Services Department
Harmony Health Plan of Illinois, Inc.
P.O. Box 31384
Tampa, FL 33631-3384

If you are not satisfied with the outcome of your complaint, you may then file the grievance with the Grievance Committee. If you need help with this, call 1-800-608-8158 (TTY 1-877-650-0952).

  • Grievances to the Committee must be in writing.
  • Grievances must be submitted within one year of the occurrence.
    Harmony will notify you within 5 days of getting your grievance.
  • You will be given a formal hearing before Harmony’s Grievance Committee. You may bring a person of your choice to the hearing. The person can be an attorney.
  • The Grievance Committee must give you a decision in writing within 30 days after the receipt of your grievance.
  • If you are not satisfied with the resolution, you may appeal to the Illinois Department of Healthcare and Family Services and request a Fair Hearing at the address below. The resolution by the Illinois Department of HFS is final.

Fair Hearings
Illinois Department of Healthcare and Family Services
HFS Bureau of Administrative Hearings
401 South Clinton Street, 6th Floor
Chicago, IL 60607


File an appeal or grievance online.
    



Last modified: 05/03/2012
 

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