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Information for Essence Members
Grievances & Complaints
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your medical care as a plan member. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Essence or penalized in any way if you make a complaint. You have the right to get a summary of information about the grievances and appeals that members have filed against Essence in the past. To get this information, call Member Services at the numbers shown below.
What is a Grievance?
A "grievance" is different from a request for a coverage determination or a request for an appeal as described on the Appeals & Grievances, Exceptions & Coverage Determinations page of this web site, which deals with Part D prescription drug benefits. "Grievances" also do not involve complaints/problems related to coverage or what benefits or services we will provide you, complaints about being discharged from the hospital too soon, or complaints about your coverage for Skilled Nursing Facility, Home Health Agency, or Comprehensive Outpatient Rehabilitation Facility services ending too soon. For these problems, you must see your Evidence of Coverage.
If you have a complaint about your Part D prescription drug benefits, please see Appeals & Grievances, Exceptions & Coverage Determinations.
The following types of problems might lead you to file a grievance:
- Problems with the quality of care you receive, including quality of care during a hospital stay
- If you feel that you are being encouraged to leave (disenroll from) Essence
- Problems with the Member Services you receive
- Problems with how long you have to spend waiting on the phone, in the waiting room, in a network pharmacy, or in the exam room
- Problems with getting appointments when you need them, or having to wait a long time for an appointment
- Disrespectful or rude behavior by doctors, nurses, receptionists, network pharmacists, or other staff
- Cleanliness or condition of doctors' offices, clinics, network pharmacies, or hospitals
- If you disagree with our decision not to expedite your request for an expedited coverage determination, organization determination, redetermination, or reconsideration
- You believe our notices and other written materials are difficult to understand
- Failure to give you a decision within the required timeframe
- Failure to forward your care to the independent review entity if we do not give you a decision within the required timeframe
- Failure by the Plan to provide required notices
- Failure to provide required notices that comply with CMS standards
If you have any of these types of problems and want to make a complaint, it is called "filing a grievance".
Filing a Grievance with Essence
If you have a complaint, we encourage you to first call Member Services at the numbers shown below. We will try to resolve any complaint that you might have, over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints, which we call our grievance process. See your Evidence of Coverage for more information about the grievance process.