Complaints, Grievances and Appeals
All Prospect Medical members 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 a 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 the member’s assigned health plan either by phone or in writing. Should the grievance be received or sent directly to Prospect Medical, it will be forwarded by the Quality Improvement Department to the member’s health plan within 24 hours.
An appeal is a written or verbal request to reconsider the initial determination of a denied healthcare service or claim. Appeals can be requested by submitting a written or verbal notification to your health plan representative to appeal any decision that the member believes is unfair or unjust.