Unison Health Plan - Complaint Process

Member Grievances (Complaints) and Appeals Procedures

If You Are Unhappy or Do Not Agree With a Decision We Made

If you are unhappy with anything about Unison Health Plan or its providers you should contact us as soon as possible. This includes if you do not agree with a decision we have made. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to let us know this. Unison Health Plan wants you to contact us so that we can help you.

To contact us you can:

Call Member Services at 1.877.877.8159, or for members with hearing or speech impairments, call our TTY line at 888.616.0021.
Fill out the Grievance and Appeal form on pages 20-21 in your Member Handbook. (You can also request a Grievance and Appeal by calling Member Services.)
Write a letter telling us what you are unhappy about. Include in your letter your first and last name, the number from the front of your Unison Health Plan member ID card, and your address and telephone number so that we can contact you, if needed. You should also send any information that helps explain your problem.
Mail the form or your letter to:
Grievance and Appeals
Unison Health Plan of Delaware
Unison Plaza
1001 Brinton Road
Pittsburgh, PA 15221

How Will Unison Respond To Your Grievance or Appeal?

Unison Health Plan will send you something in writing if we make a decision to: Deny a request to cover a service for you. Reduce, suspend or stop care you are already receiving. Deny payment for a service you received that is not covered by Unison Health Plan.

We will also send you something in writing if, by the date we should have, we did not: Make a decision on whether to okay a request to cover a service for you. Give you an answer to something you told us you were unhappy about.

Member Appeals

If you do not agree with the decision or action listed in the letter, you can call us at 1.877.877.8159 or write to us within 90 calendar days to ask that we change our decision. This is an appeal. Written appeals must be mailed to:

Grievances and Appeals
Unison Health Plan of Delaware
1001 Brinton Road
Pittsburgh, PA 15221

We will answer your appeal in writing within 45 calendar days from the date you contacted us. This time frame may be extended by up to 14 days if you ask us to extend it or if we decide it would be in your best interest. The decision letter will tell you what to do if you don’t like our decision. If you call us to file your appeal, someone from Unison will put your appeal in writing and send it to you for your signature. If you want your doctor to file the appeal for you, you must give your written approval for your doctor to do this.

We will send you a letter telling you that we received your appeal. You may ask for help with your appeal. During the appeal process, you can have someone you know represent you or act on your behalf. If you decide to have someone represent you or act for you, tell Unison in writing the name of that person and how we can reach him or her. You or the person you choose to represent you (“your representative”) may ask Unison to see any information relevant to your appeal. You may also send information that you have about your appeal to:

Grievance and Appeals
Unison Health Plan of Delaware
1001 Brinton Road
Pittsburgh, PA 15221

You and your representative may appear by video conference or by phone at the appeal review and bring a family member, friend, lawyer or other person to help you. If you want to appear by phone or by video conference, call Member Services at 1.877.877.8159 within 5 business days of the date of the letter that we send to you telling you we received your appeal.

If you need help with your appeal, call Member Services. Unison will assign someone who has not been involved in the appeal to help you at no charge.

If your doctor thinks that usual time frames for deciding your appeal will harm your health, s/he can call Unison and ask that your appeal be decided faster. Your doctor must fax a letter to 1.412.457.1359 saying why you need a faster appeal. Unison will make a decision and call you with our decision within 3 working days of getting your request for an expedited appeal. You can request an extension up to 14 days. You will also get a letter telling you the reasons for the decision and what to do if you don’t like the decision.

Member Grievances

If you contact us because you are unhappy with something about Unison or one of our doctors, this is called a grievance. Unison will answer your grievance in writing within 45 calendar days from the date you contacted us.

During the grievance process, you can have someone you know represent you or act on your behalf. If you decide to have someone represent or act for you, tell Unison, in writing, the name of that person and how we can reach him or her. You or the person you choose to represent you (“your representative”) may ask Unison to see any information relevant to your grievance. You may also send information that you have about your grievance to:

Grievance and Appeals
Unison Health Plan of Delaware
1001 Brinton Road
Pittsburgh, PA 15221

You and your representative may appear by phone or video conference at the grievance review. You may also bring a family member, friend, lawyer or other person to help you. If you want to appear by phone or video conference at the review, call Member Services at 1.877.877.8159 within 10 days of the date of the letter telling you we received your grievance.

If you need help with your grievance, call Member Services and Unison will assign someone who has not been involved in your issue to help you at no charge.

State Fair Hearings

You may file a request for a state fair hearing directly with the Delaware Department of Health and Social Services if Unison has made a decision to reduce, suspend, stop or deny any care you are receiving, fails to promptly deliver a service or denies payment for a service. You do not need to exhaust Unison’s appeal process before asking for a state fair hearing. You must ask for your state fair hearing within ninety (90) calendar days of the date of Unison’s notice of action or the date of Unison’s written appeal decision. You can mail your request to:

DSS Fair Hearing Officer
Herman M. Holloway Campus, Lewis Bldg
P.O. Box 907
New Castle, DE 19720

A state hearing is a meeting with you, someone from Unison Health Plan and a hearing officer from the Delaware Department of Health and Social Services. Unison will explain why we made our decision. You can then say why you think we made a mistake. The hearing officer will listen and then decide who is right based on the information given and whether we followed the rules.

If you have been getting an ongoing service or item that is being reduced, changed or stopped, you may continue to get the service if your appeal or state fair hearing is received within 10 days of the date on either Unison’s notice of action or the appeal decision letter and you request that the service be continued.

If after the hearing, the State of Delaware decides that Unison’s decision was correct, you may be responsible for payment of the services that you received while your appeal was being reviewed. If the State of Delaware decides that Unison’s decision was wrong, your services will be authorized and Unison will arrange for you to get them immediately.