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.

Members have the right to file a discrimination complaint with the United States Department of Health and Human Services Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex electronically through the Office for Civil Rights Complaint Portal or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Complaint forms are available at the U.S. Department of Health and Human Services website. Complaints filed with the U.S. Department of Health and Human Services, Office for Civil Rights must be filed within 180 days of the date of the alleged discrimination.