Customer Service is Now Member Experience

Examples of situations appropriate for a grievance include the following. • Network Health will not approve care you believe should be covered. • Network Health is ending coverage on care you still need. • Network Health has denied payment for services or items you have received, and you think they should be covered.

Who may file a grievance? You or someone you name to act for you (called your representative) may file a grievance. To name your representative, visit networkhealth.com and go to the Member Resources page (under Employer Plans if you get coverage through your employer or Individual and Family Plans if you buy insurance on your own). Complete the Appointment of Representative Form and send it to the address listed on the form.

What happens after I file a grievance? When you file a grievance, you are formally requesting Network Health to review our decision. We will acknowledge your grievance within five business days of receiving it. The Grievance Committee will schedule a hearing to review your case and you will be notified at least seven days prior to that meeting. Before the meeting, you have the right to submit written comments, documents, records and information relevant to your grievance. You may attend the grievance meeting in person or on the phone to present any additional information. After the hearing, the Grievance Committee will address your grievance and provide a written response within 30 calendar days for a pre-service claim or 60 calendar days for a post-service claim.

How are medication grievances handled? Medication grievances should be submitted in writing and are reviewed by a Network Health pharmacist and Network Health medical director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed or discusses alternative covered medications. Our pharmacists strive to address medication appeals within four hours and have been successful over 90 percent of the time.

When do I file a complaint? If you’re dissatisfied with the service or quality provided by your plan or doctor, we can help you work through any issues. You have the right to file a formal complaint about the service you receive from Network Health, our vendors or contracted providers.

These are examples of situations appropriate for a grievance. • Concerns about the quality of care or services provided • Interpersonal aspects of care (for example, rudeness of a provider or staff) • Failure to respect your rights

Say What?

Pre-service claim is prior authorization of a service or • Difficulty getting through on the phone

procedure

Post service claim is a claim that is processed after the service has been performed

Kathy W., Member Experience Team Member

Customer Service is Now Member Experience

Our customer service team has changed its name to the member experience team. This new name considers your entire journey, which is made up of all the experiences you have when interacting with Network Health.

At Network Health, you’re more than a customer. We know we are serving our neighbors, friends and family. The member experience team name is about supporting the best part of Network Health— you, our member. This team still provides the same great service you’ve come to expect—assisting with benefits, claims, authorizations, pharmacy and more. Now we’re just doing it with a name that more accurately describes what we do.