Medicaid Complaints, Grievances, and Fair Hearings


If a provider or Highmark Wholecare does something that you are unhappy about or do not agree with, you can tell Highmark Wholecare or the Department of Human Services what you are unhappy about or that you disagree with what the provider or Highmark Wholecare has done. This section describes what you can do and what will happen.

Complaints

A Complaint is when you tell Highmark Wholecare you are unhappy with Highmark Wholecare or your provider or do not agree with a decision by Highmark Wholecare.

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 have not gotten services that Gateway Health has approved.
  • You were denied a request to disagree with a decision that you have to pay your provider.

Grievances

When Highmark Wholecare 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 notice telling you Highmark Wholecare’s decision.

A Grievance is when you tell Highmark Wholecare you disagree with Highmark Wholecare’s decision.


Fair Hearings

In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something Highmark Wholecare did or did not do. These hearings are called “Fair Hearings.” You can ask for a Fair Hearing after Highmark Wholecare decides your First Level Complaint or decides your Grievance.



This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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