APPEALS & GRIEVANCES FOR STATE, EDUCATION, LOCAL GOVERNMENT AND FEDERAL EMPLOYEES AND COMMERCIAL MEMBERS
Member Appeals and Grievance Procedures
In accordance with Federal, State, and GlobalHealth standards, GlobalHealth ensures timely response and resolution of member complaints by providing a process which includes documentation, investigation, notification and timely resolution.
Appeals and Grievances
An appeal is a request for reconsideration of a decision to deny services or payment of services (i.e., a denied benefit, claim or service). Appeals will follow the standard or expedited process. An expedited appeal is a request to change an adverse determination for urgent care where the standard appeal process could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Expedited appeals apply only to decisions to deny services.
A grievance is an oral or written expression of dissatisfaction. Grievances may consist of quality of care and/or quality of service issues, such as office waiting times, physician behavior or adequacy of facilities. GlobalHealth will attempt to resolve any complaint that the member might have. We encourage the informal resolution of complaints. However, if the complaint cannot be resolved in this manner, a more formal Member Grievance Procedure is available.
Timeframe for Resolving Appeals and Grievances
The following timeframe applies to each appeal and grievance:
- Members must file their appeals within 180 days after the denial notification.
- Standard appeals (denial of service) must be resolved within 30 days of receipt by GlobalHealth.
- Expedited appeals (denial of service) must be resolved within 72 hours of receipt by GlobalHealth.
- Standard appeals (denial of payment of a service already rendered) must be resolved within 60 days of receipt by GlobalHealth.
- Grievances must be resolved within 30 days of receipt by GlobalHealth.
- The Timeframe regarding GlobalHealth's resolution may be extended upon agreement by the member.
Levels of Review
An additional level of review for services greater than $1,000.00 through the State of Oklahoma is available to members who file appeals should GlobalHealth uphold its original decision.
Who May File an Appeal or a Grievance
A grievance or appeal can be filed by a member or someone else appointed by the member to file the appeal on his or her behalf. To appoint someone else as your representative, please provide the following:
- Provide GlobalHealth a statement that appoints him/her to act on your behalf.
"I [member name] appoint [name of representative] to act as my representative in requesting an appeal from GlobalHealth regarding ________________________ (insert the type of denial or discontinuation of service)."
- Include the member's GlobalHealth Identification number.
- Include the appointed representative's relationship to the member.
- Include both the member and the appointed representative’s address and telephone number.
- Both the member and the representative must sign and date the statement.
An expedited appeal may be filed by a physician on behalf of the member without submitting a member representative form.
How to Access the Appeals and Grievances Process
Contact GlobalHealth Customer Care at (877) 280-5600, or you may submit a written statement containing the following information:
- Your name and address
- Your GlobalHealth membership ID #
- Provider of service
- Copy of claims (if applicable)
- A complete and accurate explanation of your appeal or grievance and the resolution you are seeking.
Forms are available upon request by calling GlobalHealth Customer Care at (405) 280-5600 (local), (877) 280-5600 (toll-free) or 711 or (800) 722-0353 (TTY/TDD/Voice), Monday-Friday, from 9:00AM-5:00PM. Submit your written statement to: GlobalHealth, Appeals and Grievances Department, 701 NE 10th St., Suite 300, Oklahoma City, OK 73104.
GlobalHealth will send a written acknowledgment of the receipt of your appeal or grievance and an explanation of the review procedure within five (5) calendar days of receipt.