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Member Privacy Policy

This Members Privacy Policy notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The law says we must help protect our members’ privacy. These are the rules that Unison and its affiliates use to do that job. We must follow these rules. We make sure that the providers and everyone else who works with us agree to help protect your privacy and use these rules. We can change our privacy rules. If we do, the new rules will apply to all the information we have about you. If we make changes, we will send you updated information.

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Complaints

A complaint is when you tell us you are unhappy with Unison Health Plan or your provider or do not agree with a decision by Unison Health Plan. Some things you may complain about:

you are unhappy with the care you are getting
you cannot get the service or item you want because it is not a covered service or item
you did not get a service that Unison Health Plan has approved.

Click here to access a form.

First Level Complaint

To file a complaint, you can:

call Unison Health Plan at 1.800.414.9025 and tell us your complaint, or
write down your complaint and send it to us at:

Attn: Pennsylvania Grievance and Appeals Department
Unison Administrative Services
Unison Plaza
1001 Brinton Road
Pittsburgh, PA 15221

You must file a complaint within 45 days of getting a letter telling you that: Unison Health Plan has decided that you cannot get a service or item you want because it is not a covered service or item.
Unison Health Plan will not pay a provider for a service or item you got.
Unison Health Plan did not decide a complaint or grievance you told us about within 30 days.

You may file all other complaints at any time.

After you file your complaint, you will get a letter from Unison Health Plan telling you that we have received your complaint, and about the first level complaint review process. You may ask Unison Health Plan to see any information we have about your complaint. You may also send information that may help with your complaint to Unison Health Plan.

You may attend the complaint review if you want to. You may come to our offices or be included by phone or by videoconference where available. If you decide that you do not want to attend the complaint review, it will not affect our decision.

A committee of two or more Unison Health Plan staff, who have not been involved in the issue you filed your complaint about, will review your complaint and make a decision. Your complaint will be decided no later than 30 days after we receive your complaint.

A decision letter will be mailed to you within five business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision. If you need more information about help during the complaint process, please call Member Services.

If you have been receiving services or items that are being reduced, changed or stopped, and you file a complaint that is hand-delivered or postmarked within 10 days of the mail date on the letter (notice) telling you that the services or items you have been receiving are not covered services or items for you, the service or items will continue until a decision is made.

Second Level Complaint

If you do not agree with our first level complaint decision, you may file a second level complaint with Unison Health Plan. You must file your second level complaint within 45 days of the date you receive the first level complaint decision letter. Use the same address or phone number you used to file your first level complaint.

You will receive a letter from Unison Health Plan telling you that we have received your complaint, and telling you about the second level complaint review process.

You may ask Unison Health Plan to see any information we have about your complaint. You may also send information that may help with your complaint to Unison Health Plan.
You may attend the complaint review if you want to. You may come to our offices or be included by phone or by videoconference where available. If you decide that you do not want to attend the complaint review, it will not affect our decision.

A committee made up of three or more people, who have not been involved in the issue you filed your complaint about, will review your complaint and make a decision. Your complaint will be decided no later than 30 days after we receive your complaint. At least one third of the second level complaint review committee may not be employees of the plan or of a related subsidiary or affiliate.

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a second level complaint that is hand-delivered or postmarked within ten days of the mail date on the first level complaint decision letter, the service or items will continue until a decision is made.

External Complaint Review

If you do not agree with Unison Health Plan’s second level complaint decision, you may ask for an external review by either the Department of Health or the Insurance Department. The Department of Health handles complaints that involve the way a provider gives care or services. The Insurance Department reviews complaints that involve Unison Health Plan policies and procedures.

You must ask for an external review within 15 days of the date you received the second level complaint decision letter. If you ask, the Department of Health will help you put your complaint in writing.

You must send your request for an external review in writing to either:

Pennsylvania Department of Health
Bureau of Managed Care
Attention: Complaint Appeals
P.O. Box 90
Harrisburg, Pennsylvania 17108-0090
1.888.466.2787

Pennsylvania Insurance Department
Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, Pennsylvania 17120
1.877.881.6388

If you send your request for an external review to the wrong department, it will be sent to the correct department.

The Department of Health or the Insurance Department will get your file from Unison Health Plan. You may also send them any other information that may help with the external review of your complaint.

You may be represented by an attorney or another person during the external review.

A decision letter will be sent to you after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a request for an external complaint review that is hand-delivered or postmarked within 10 days of the mail date on the second level complaint decision letter, the service or items will continue until a decision is made.

When Unison Health Plan denies, decreases, or approves a service or item different than the service or item you requested because it is not medically necessary, you will get a letter (notice) telling you Unison Health Plan’s decision.

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

First Level Grievance

You have 45 days from the date you receive the letter (notice) that tells you about the denial, decrease, or approval of a different service or item, to file your grievance. To file a grievance, you can:

call Unison Health Plan at 1.800.414.9025 and tell us your grievance, or
write to us at:

Attn: Pennsylvania Grievance and Appeals Department
Unison Administrative Services
Unison Plaza
1001 Brinton Road

Your provider can file a grievance for you if you give the provider your consent in writing. If your provider files a grievance for you, you cannot file a separate grievance on your own.

After you file your grievance, you will get a letter from Unison Health Plan telling you that we have received your grievance, and about the first level grievance review process.

You may ask Unison Health Plan to see any information we have about your grievance. You may also send information that may help with your grievance to Unison Health Plan.

You may attend the grievance review if you want to. You may come to our offices or be included by phone or by videoconference where available. If you decide that you do not want to attend the grievance review, it will not affect our decision.

A committee of two or more Unison Health Plan staff, including a licensed doctor, who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision. Your grievance will be decided no later than 30 days after we received your grievance.

If you have been receiving services or items that are being reduced, changed or stopped and you file a grievance that is hand-delivered or postmarked within ten days of the mail date on the letter (notice) telling you that the services or items you have been receiving are being reduced, changed or stopped, the service or items will continue until a decision is made.

Second Level Grievance

If you do not agree with our first level grievance decision, you may file a second level grievance with Unison Health Plan.

You must file your second level grievance within 45 days of the date you received the first level grievance decision letter. Use the same address or phone number you used to file your first level grievance.

You will receive a letter from Unison Health Plan telling you that we have received your grievance, and telling you about the second level grievance review process.

You may ask Unison Health Plan to see any information we have about your grievance. You may also send information that may help with your grievance to Unison Health Plan.

A committee of three or more people including a doctor, who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision. Your grievance will be decided no later than 30 days after we received your grievance.

If you have been receiving services or items that are being reduced, changed or stopped and you file a second level grievance that is hand-delivered or postmarked within ten days of the date on the first level grievance decision letter, the service or items will continue until a decision is made.

External Grievance Review

If you do not agree with Unison Health Plan’s second level grievance decision, you may ask for an external grievance review.

You must call or send a letter to Unison Health Plan asking for an external grievance review within 15 days of the date you received our grievance decision letter. Use the same address and phone number you used to file your first level grievance. We will then send your request to the Department of Health.

The Department of Health will notify you of the external grievance reviewer’s name, address and phone number. You will also be given information about the external review process.

Unison Health Plan will send your grievance file to the reviewer. You may provide additional information that may help with the external review of your grievance to the reviewer, within 15 days of filing the request for an external grievance review.

You will receive a decision letter within 60 days of the date you asked for an external grievance review. This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

If you have been receiving services or items that are being reduced, changed or stopped, and you request an external grievance review that is hand-delivered or postmarked within ten days of the mail date on the second level grievance decision letter, the service or items will continue until a decision is made.

You may call Unison Health Plan’s toll-free telephone number at 1.800.414.9025 if you need help or have questions about complaints and grievances. You can contact Pennsylvania Legal Services at 1.800.322.7572 or call the Pennsylvania Health Law Project at 1.800.274.3258.

Expedited Complaints and Grievances

If your doctor or dentist believes that the usual timeframes for deciding your complaint or grievance will harm your health, you or your doctor or dentist can call Unison Health Plan at 1.800.414.9025 and ask that your complaint or grievance be decided faster. You will need to have a signed letter from your doctor or dentist faxed to 412.457.1434 explaining how the usual timeframe for deciding your complaint or grievance will harm your health.

If your doctor or dentist does not fax Unison Health Plan this letter, your complaint or grievance will be decided within the usual timeframes.

Unison Health Plan will make a faster decision on your grievance with a letter from your doctor or dentist. Unison Health Plan will only make a faster decision on complaints about services not provided timely or non-covered services or items with a letter from your doctor or dentist.

Expedited Complaint

The expedited complaint will be decided by a provider who has not been involved in the issue you filed your complaint about.

Unison Health Plan will call you within three business days of when we receive your request for an expedited (faster) complaint review with our decision. You will also receive a letter telling you the reason(s) for the decision and how to file a second level complaint, if you don’t like the decision.

An expedited complaint decision may not be requested after a second level complaint decision has been made on the same issue.

Expedited Grievance and Expedited External Grievance

A committee of three or more people, including a licensed doctor, will review your grievance. The licensed doctor will decide your expedited grievance with help from the other people on the committee. No one on the committee will have been involved in the issue you filed your grievance about.

Unison Health Plan will call you within three business days of when we receive your request for an expedited (faster) grievance review with our decision. You will also receive a letter telling you the reason for the decision and, that you can ask for an expedited external grievance review, if you do not like the decision.

If you want to ask for an expedited external grievance review by the Department of Health, you must call Unison Health Plan at 1.800.414.9025 within 2 business days from the date you get the expedited grievance decision letter. Unison Health Plan will send your request to the Department of Health within 24 hours after receiving it.

An expedited grievance decision may not be requested after a second level grievance decision has been made on the same issue.

What kind of help can I have with the complaint and grievance processes?

If you need help filing your complaint or grievance, a staff member of Unison Health Plan will help you. This person can also represent you during the complaint or grievance process. You do not have to pay for the help of a staff member. This staff member will not have been involved in any decision about your complaint or grievance.

You may also have a family member, friend, lawyer or other person help you file your complaint or grievance. This person can also help you if you decide you want to appear at the complaint or grievance review. For legal assistance you can contact your local legal aid office at 1.800.322.7572.

At any time during the complaint or 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 Health Plan, in writing, the name of that person and how we can reach him or her.

You or the person you choose to represent you may ask Unison Health Plan to see any information we have about your complaint or grievance.

For persons whose primary language is not English: If you ask for language interpreter services, Unison Health Plan will provide the services at no cost to you.

For persons with Disabilities: Unison Health Plan will provide persons with disabilities with the following help in presenting complaints or grievances at no cost, if needed. This help includes:

providing sign language interpreters;

providing information submitted by Unison Health Plan at the complaint or grievance review in an alternative format. The alternative format version will be given to you before the review; and

providing someone to help copy and present information.

For some issues you can request a fair hearing from the Department of Public Welfare in addition to or instead of filing a complaint or grievance with Unison Health Plan.

Department of Public Welfare Fair Hearings

In some cases you can ask the Department of Public Welfare to hold a hearing because you are unhappy about or do not agree with something Unison Health Plan did or did not do. These hearings are called “fair hearings”. You can ask for a fair hearing at the same time you file a complaint or grievance or you can ask for a fair hearing after Unison Health Plan decides your first or second level complaint or grievance.
You must ask for a fair hearing in writing and send it to:

Department of Public Welfare
Office of Medical Assistance Programs – HealthChoices Program
Complaint, Grievance and Fair hearings
PO Box 2675
Harrisburg, PA 17105-2675

You must ask for a fair hearing within 30 days of getting a letter telling you that:

Unison Health Plan decided that you cannot get a service or item you want because it is not a covered service or item
Unison Health Plan will not pay a provider for a service or item you got and the provider can bill you for the service or item
Unison Health Plan did not decide a complaint or grievance you told them about within 30 days
Unison Health Plan decided to deny, decrease or approve a service or item different than the item or service your doctor or dentist requested because it was not medically necessary.

If you believe Unison Health Plan did not provide a service or item by the time you should have received it, you must ask for a fair hearing within 30 days of the date you should have received the service or item.

Your request for a fair hearing should include the following information:

member name;
member social security number and date of birth;
a telephone number where you can be reached during the day;
if you want to have the fair hearing in person or by telephone; and
any letter you may have received about the issue you are requesting your fair hearing for.

What happens after I ask for a fair hearing?

You will get a letter from the Department of Public Welfare’s Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing. You will receive this letter at least ten days before the date of the hearing.

You may come to where the fair hearing will be held or be included by phone. A family member, friend, lawyer or other person may help you during the fair hearing.
Unison Health Plan will also go to your fair hearing to explain why we made the decision or explain what happened.

If you ask, Unison Health Plan must give you any records, reports and other information we have that is relevant to what you requested your fair hearing about.

If you ask for a fair hearing after a first level complaint or grievance decision, the fair hearing will be decided no more than 60 days after the Department of Public Welfare gets your request.

If you ask for a fair hearing and did not file a first level complaint or grievance, or if you ask for a fair hearing after a second level complaint or grievance decision, the fair hearing will be decided within 90 days from when the Department of Public Welfare gets your request.

If your appeal is not decided within 90 days from the date that the Department of Welfare receives your request, you may be able to get interim assistance until the decision is made.

If you have been receiving services or items that are being reduced, changed or stopped; and your request for a fair hearing is hand-delivered or postmarked within ten days of the mail date on the letter (notice) telling you that Unison Health Plan has reduced, changed or denied your services or items or telling you Unison Health Plan’s decision about your first or second level complaint or grievance, your services or items will continue until a decision is made.

Expedited Fair Hearing

If your doctor or dentist believes that using the usual timeframes to decide your fair hearing will harm your health, you or your doctor or dentist can call the Department of Public Welfare at 1.800.798.2339 and ask that your fair hearing be decided faster. This is called an expedited fair hearing. You will need to have a signed letter from your doctor or dentist faxed to 717.772.6328 explaining why using the usual timeframes to decide your fair hearing will harm your health. If your doctor or dentist does not send a written statement, your doctor or dentist may testify at the fair hearing to explain why using the usual timeframes to decide your fair hearing will harm your health.

The Bureau of Hearings and Appeals will contact you to schedule the expedited fair hearing. The expedited fair hearing will be held by telephone within three business days after you ask for the fair hearing.

If your doctor does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited. Another hearing will be scheduled, and the time frame for the fair hearing decision will be based on the date you asked for the fair hearing.

If your doctor sent a written statement or testifies at the hearing, the decision will be made within three business days after you asked for the fair hearing.

You may call Unison Health Plan’s toll-free telephone number at 1.800.414.9025 if you need help or have questions about fair hearings. You can contact Pennsylvania Legal Services at 1.800.322.7572 or call the Pennsylvania Health Law Project at 1.800.274.3258.

HealthChoices Office of Medical Assistance Programs (OMAP)

The Office of Medical Assistance Programs (OMAP) was set up by the Medical Director for the Office of Medical Assistance Programs at the Department of Public Welfare (DPW). The OMAP was developed to ensure that the HealthChoices HMOs and behavioral health plans honor your right to have your request for medically necessary care and services responded to in a timely manner. The OMAP helps all Medical Assistance recipients who are enrolled in the HealthChoices Program.

The OMAP is answered by nurses who work for DPW. If you or your medical provider have requested medical care or services and your HMO or behavioral health plan has not responded in time to meet your needs, call the OMAP. The OMAP will make sure that the HMO or behavioral health plan responds to your request soon enough to meet your needs. You can also call the OMAP if your HMO or behavioral health plan has denied you medically necessary care or services and won’t accept your request to file a grievance.

The OMAP operates Monday through Friday between 9:00 am and 5:00 pm. Call 1.800.426.2090.

The OMAP can not provide or approve urgent or emergency medical care. If you believe you have an urgent or emergency medical situation, you should seek the care you need with your PCP or local hospital.