All members of Prospect Medical have the right to file a grievance or appeal any decision.
By definition, a grievance is a written or verbal expression of a member’s dissatisfaction with the care or services provided, and may be used to request review of a complaint or inquiry that has not been resolved to the member’s satisfaction.
A complaint (or inquiry) is a member’s written or verbal request for information or assistance, or an expression of concern about an issue. A complaint can become a grievance.
Complaints and/or grievances should be submitted to Prospect Medical’s Customer Service Department at 800-708-3230, or to the appropriate health plan either verbally or in writing. Should the grievance be forwarded directly to Prospect Medical, it will be reviewed by our Quality Team for resolution, and forwarded to the appropriate health plan.
An appeal is a written or verbal request to reconsider the initial determination of a denied healthcare service or claim. Appeals can be requested in several ways, including by:
- Submitting a written or verbal notification to your health plan representative to appeal any decision that you believe is unfair or unjust
- Submitting a written or verbal notification to the Prospect Medical contracted provider (physician) to appeal a decision
- Submitting a faxed, written or verbal notification through Prospect Medical’s Customer Service Department at 800-708-3230. All appeals will be forwarded to your health plan.
Complaints, grievances and appeals all must be filed within specified time frames as dictated by each member’s health plan.