A complaint is when you are unhappy with Unison Kids for your child or if you are unhappy with the provider.

Examples of a complaint:

• You are unhappy with the care your child’s provider is giving your child.
• You are unhappy with the services your child is receiving from the plan.
• You are unhappy that payment was denied for a service not included on the Unison Kids program or in your child’s benefit package.

What Should I Do if I Have a Complaint?

Within 45 days from the incident you are complaining of, make your complaint by writing to Unison Kids at:

Unison Administrative Services
Kids Grievance and Appeals Department
Unison Plaza
1001 Brinton Road
Pittsburgh, PA  15221

Unison Kids will investigate/review the complaint within 30 days of receipt. You will be sent a letter from Unison Kids telling you of the decision within five business days after the decision is reached.

You may ask for help. A staff member will help you make your child’s complaint or represent your child during the complaint process. This staff member has never made a decision related to any part of your child’s care. Members needing help with filing a complaint should call Unison Kids. For more information, we are available Monday, Tuesday, Thursday and Friday from 8:00 a.m. to 5:00 p.m. and Wednesday 8:00 a.m. to 8:00 p.m. You can reach us at 800.414.9025 or TTY1.888.616.0021.

What if I Am Unhappy with the Unison Kids Decision?

You may make a Second Level Complaint with Unison Kids by sending your complaint within45 days of your receipt of the first level complaint decision letter. You have the right to meet with the Second Level Complaint Committee and voice your complaint for your child. Unison Kids will conduct the second level review within 30 days from the receipt of the request for a Second Level Complaint.

You will be sent a letter from Unison Kids within five business days after the Second Level Complaint Committee reaches a decision.

What Can I Do if I Am Still Unhappy with the Unison Kids Decision?

You have 15 days from receiving a Unison Kids decision letter to file an Appeal of Complaint with either the Department of Health or the Insurance Department that handles this complaint. 

The Department of Health handles complaints that involve the way a provider gives care or service. The Insurance Department reviews complaints that involve Unison Kids’ policies and procedures. If you file your complaint with the wrong department, your complaint will be forwarded for you to the correct department. You must send your complaint in writing to either:

Bureau of Managed Care
Department of Health
Attn: Complaints Appeals
PO Box 90
Harrisburg, PA 17108-0090
1.888.466.2787

OR

Insurance Department
Bureau of Consumer Services
Room 1321, Strawberry Square
PO Box 90
Harrisburg, Pennsylvania 17120
1.877.881.6388

You may also send additional information that you feel will help with the complaint. You maybe represented by an attorney or other individual before the appropriate department.

A grievance is when you are unhappy about Unison Kids’ decision to deny payment for a service, to approve payment for a decrease in service or to approve payment for a service different than the service requested because Unison Kids feels it is not medically necessary for your child.

How do I Make a Grievance?

When Unison Kids makes a denial, approves payment for a decrease in a service, or approves payment for a service different than the service requested, you will receive a letter that tells you about our grievance process. Our grievance process has two steps: First Level Grievance and Second Level Grievance.

For both the First and Second Levels of the Grievance Process, you may send the grievance in letter form or if you have a disability or if you speak a different language you may call Unison Kids at 1.800.414.9025 (TTY888.616.0021).

Unison Kids will put your grievance into written form for you. If you want your provider to file the grievance for you, you must give your written approval for the provider to do so. You should send your written grievance to:

Unison Administrative Services
Kids Grievance and Appeals Department
Unison Plaza
1001 Brinton Road
Pittsburgh, PA  15221

You have 45 days from the date when you receive the notice of denial for payment or approval of payment for a decrease or different service, to file your grievance.

If payment for services your child is currently receiving is being denied, reduced or approved for a different service, you may want to continue services through the grievance process. To do this, you must file the grievance with Unison Kids within ten days from the date of the notice.

You may ask for help. A staff member will help you make the grievance or represent your child during the grievance process. This staff member has never made a decision related to any part of your child’s care.

Grievances

A grievance is when you tell us you disagree with Unison Health Plan’s decision.

First Level Grievance

Unison Kids will review your First Level Grievance within 30 days. Within five business days after the First Level Grievance review is completed, Unison Kids will send you a letter with the decision. This letter will tell you the reason for the decision, and if you want, how to file a Second Level Grievance.

Second Level Grievance

You may file a second level grievance within45 days of your receipt of the First Level decision letter. Unison Kids will review the Second Level Grievance within 30 days of the receipt of the request for a Second Level Grievance. You may come to the Second Level Grievance Committee meeting. You may bring someone, such as a friend, relative, or your child’s provider with you to help you with your grievance.

Within five business days after the Second Level Grievance review is completed, Unison Kids will send you a letter with the decision. This letter will tell you the reason for our decision and what to do if you are still not happy with our decision.

What Can I Do If My Child’s Health is at Immediate Risk?

You can file an Expedited Internal Grievance with Unison Kids if your child’s doctor certifies in writing that your child’s health would be jeopardized by the normal grievance process. The grievance will be reviewed within 48 hours. You will receive a call and a letter from Unison Kids with the decision.

What Can I do if I am Still Unhappy with the Unison Kids Decision?

You can file an External Grievance Review.

External Grievance Procedure

You may get a review of the grievance by someone other than Unison Kids. The External Grievance will take place outside of Unison Kids and can only be used after the Internal Grievance Process is exhausted. You must send a letter to Unison Kids requesting an External Grievance within 15 days of receiving the Second Level decision letter. You can use the Unison Administrative Services address as listed on page 23 for filing a grievance. Unison Kids will send your External Grievance request to an independent external reviewer assigned by the Pennsylvania Department of Health. You will be notified within two business days of the assignment of the Utilization Review Entity. You may send additional information that helps with the grievance to the External Grievance Reviewer. You will receive a letter with the External Grievance Reviewer’s decision within 60 days of the filing of the External Grievance.