Complaints & Grievances
You feel you were not treated with respect
You are not satisfied with the health care you got
It took too long to get an appointment
To file a Complaint/Grievance, you should call Member Services at 202-218-0380.
Your doctor can also file a Complaint/Grievance for you.
You should file a Complaint/Grievance as soon as possible and no later than 90 days after the thing you are unhappy about. Health Right will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision.
Appeals and Fair Hearings
If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an Appeal with Health Right and request a “Fair Hearing” with the D.C.’s Office of Administrative Hearings.
To file an Appeal with Health Right call Member Services at 202-218-0380.
To file a request for a Fair Hearing, call or write the District government at:
District of Columbia Office of Administrative Hearings
Clerk of the Court
825 North Capitol Street, NE
Suite 4150
Washington, DC 20002
Telephone Number: 202-442-9091
Deadlines
You must file an Appeal or request a Fair Hearing within 90 days of the date on, Health Right’s notice of action.
If you want to continue receiving the benefit during your Fair Hearing or Appeal, you must request the Fair Hearing or Appeal within the later of the following:
Within 10 days from the postmark of the Health Right Notice of Action or
The intended effective date of Health Right’s proposed action (or, in other words, when the benefit is to stop).
Your provider may file an Appeal or request for a Fair Hearing on your behalf if you give permission.
Appeals
If you call and give your Appeal over the phone, Health Right will summarize your Appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to Health Right in order to have an Appeal.
Your Appeal will be decided by Health Right within 15 calendar days from the date your Appeal was received.
If Health Right needs more time to get information and the District decides this would be best for you, or if you or your Advocate requests more time, Health Right may increase this time period for the decision by 5 calendar days. Health Right must give you written notice of the extension.
You will receive written notice of Health Right’s decision about your Appeal in the mail.
If you are not happy with Health Right’s decision about your Appeal you may request a Fair Hearing. If you want to continue your benefits during the Fair Hearing, you must request a Fair Hearing within 10 days from the postmark of the MCO Notice of Action.
Expedited (Emergency) Complaints/Grievances and Appeals Process
If your Appeal is determined to be an emergency, Health Right will give you a decision within 3 calendar days. An Appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the Appeal procedure.
All Appeals filed by Members with HIV/AIDS, mental illness or any other condition that requires attention right away, will be resolved and communicated back to the Member within 24 hours of filing the Appeal.
Your Rights During the Complaints/Grievances, Appeals and Fair Hearings Process
You have the right to a Fair Hearing. You may request a Fair Hearing from the Office of Administrative Hearings at any time before, during or after you have filed an Appeal with Health Right, but no more than ninety (90) days from the date Notice of Action is mailed.
You have a right to keep receiving the benefit we denied while your Appeal or Fair Hearing is being reviewed. To keep your benefit during a Fair Hearing, you must request the Fair Hearing within a certain number of days - This could be as short as 10 days.
You have the right to have someone from Health Right help you through the Grievance and Appeals process.
You have a right to represent yourself or be represented by your family caregiver, lawyer, or other representative.
You have a right to have accommodations made for any special health care need you have.
You have a right to adequate TTY/TTD capabilities, and services for the visually impaired.
You have a right to adequate translation services and an interpreter.
You have a right to see all documents related to the Complaint/Grievance, Appeal or Fair Hearing.
If you have any questions about the Complaints/Grievances and Appeals/Fair Hearings process, please call Member Services at 202-218-0380 or toll free at 1-877-284-0282. For the hearing impaired community, please use your local phone company to help in a third party call using TTY communication device.
Health Right and the D.C. government both have ways that you can complain about the care you get or the Services Health Right provides to you. You may choose how you would like to complain as described below.
Complaints/Grievances
If you are unhappy with something that happened to you, you can file a Complaint/Grievance. Examples of why you might file a Complaint/Grievance include:
Your doctor can also file a Complaint/Grievance for you.
You should file a Complaint/Grievance as soon as possible and no later than 90 days after the thing you are unhappy about. Health Right will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision.
Appeals and Fair Hearings
If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an Appeal with Health Right and request a “Fair Hearing” with the D.C.’s Office of Administrative Hearings.
To file an Appeal with Health Right call Member Services at 202-218-0380.
To file a request for a Fair Hearing, call or write the District government at:
District of Columbia Office of Administrative Hearings
Clerk of the Court
825 North Capitol Street, NE
Suite 4150
Washington, DC 20002
Telephone Number: 202-442-9091
Deadlines
You must file an Appeal or request a Fair Hearing within 90 days of the date on, Health Right’s notice of action.
If you want to continue receiving the benefit during your Fair Hearing or Appeal, you must request the Fair Hearing or Appeal within the later of the following:
Within 10 days from the postmark of the Health Right Notice of Action or
The intended effective date of Health Right’s proposed action (or, in other words, when the benefit is to stop).
Your provider may file an Appeal or request for a Fair Hearing on your behalf if you give permission.
Appeals
If you call and give your Appeal over the phone, Health Right will summarize your Appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to Health Right in order to have an Appeal.
Your Appeal will be decided by Health Right within 15 calendar days from the date your Appeal was received.
If Health Right needs more time to get information and the District decides this would be best for you, or if you or your Advocate requests more time, Health Right may increase this time period for the decision by 5 calendar days. Health Right must give you written notice of the extension.
You will receive written notice of Health Right’s decision about your Appeal in the mail.
If you are not happy with Health Right’s decision about your Appeal you may request a Fair Hearing. If you want to continue your benefits during the Fair Hearing, you must request a Fair Hearing within 10 days from the postmark of the MCO Notice of Action.
Expedited (Emergency) Complaints/Grievances and Appeals Process
If your Appeal is determined to be an emergency, Health Right will give you a decision within 3 calendar days. An Appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the Appeal procedure.
All Appeals filed by Members with HIV/AIDS, mental illness or any other condition that requires attention right away, will be resolved and communicated back to the Member within 24 hours of filing the Appeal.
Your Rights During the Complaints/Grievances, Appeals and Fair Hearings Process
If you have any questions about the Complaints/Grievances and Appeals/Fair Hearings process, please call Member Services at 202-218-0380 or toll free at 1-877-284-0282. For the hearing impaired community, please use your local phone company to help in a third party call using TTY communication device.
