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Complaints

What is a complaint?

A complaint is when you tell us you are unhappy with Keystone First or your provider or you do not agree with a decision by Keystone First.

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 Keystone First has approved

What should I do if I have a complaint?

FIRST LEVEL COMPLAINT
To file a complaint, you can:

  • Call Keystone First at 1-800-521-6860 and tell us your complaint, or
  • Write down your complaint and send it to us at:

Member Appeals Department
Attention: Member Advocate
Keystone First
200 Stevens Drive
Philadelphia, PA 19113-1570
, or

  • Your provider can file a complaint for you if you give the provider your consent in writing to do so. (Note: If your provider files a complaint for you, you cannot file a separate complaint on your own.)

This is called a first level complaint.

When should I file a first level complaint?

You must file a complaint within 45 days of getting a letter telling you that:

  • Keystone First has decided that you cannot get a service or item you want because it is not a covered service or item.
  • Keystone First will not pay a provider for a service or item you received.
  • Keystone First did not decide within 30 days about a complaint or grievance you told us about before.

You must file a complaint within 45 days of the date you should have gotten a service or item if you did not get a service or item. The time by which you should have received a service or item is listed below:

Appointment standards

New member appointment for your first examination for… We will make an appointment for you...
members with HIV/AIDS with a PCP or specialist no later than 7 days after you become a member in Keystone First unless you are already being treated by a PCP or specialist.
members who receive Supplemental Security Income (SSI) with a PCP or specialist no later than 45 days after you become a member in Keystone First, unless you are already being treated by a PCP or specialist.
members under the age of 21 with a PCP for an EPSDT screen no later than 45 days after you become a member in Keystone First, unless you are already being treated by a PCP or specialist.
all other members with a PCP, no later than 3 weeks after you become a member in Keystone First.
Members who are pregnant… We will make an appointment for you...
pregnant women in their first trimester with an OB/GYN provider within 10 business days of Keystone First learning you are pregnant.
pregnant women in their second trimester with an OB/GYN provider within 5 business days of Keystone First learning you are pregnant.
pregnant women in their third trimester with an OB/GYN provider within 4 business days of Keystone First learning you are pregnant.
pregnant women with high-risk pregnancies with an OB/GYN provider within 24 hours of Keystone First learning you are pregnant.
Appointment with primary care practitioner
(PCP)
We will make an appointment for you...
urgent medical condition within 24 hours
routine appointment within 10 business days
health assessment/general physical examination within 3 weeks
Appointment with specialists (when referred by PCP) We will make an appointment for you...
urgent medical condition within 24 hours of referral
routine appointment with one of the following Specialists:
  • Otolaryngology
  • Orthopedic surgery
  • Dermatology
  • Pediatric endocrinology
  • Pediatric general surgery
  • Pediatric infectious disease
  • Pediatric neurology
  • Pediatric pulmonology
  • Pediatric rheumatology
  • Dentist
  • Pediatric allergy and immunology
  • Pediatric gastroenterology
  • Pediatric hematology
  • Pediatric nephrology
  • Pediatric oncology
  • Pediatric rehab medicine
  • Pediatric urology
within 15 business days of referral
routine appointment with all other Specialists within 10 business days of referral

You may file all other complaints at any time.

What happens after I file a first level complaint?

After you file your complaint, you will get a letter from Keystone First telling you that we have received your complaint, and about the first level complaint review process.

You may ask Keystone First to see and ask for a copy of any information we have about your complaint. You may also send information to Keystone First that may help with your complaint.

You may attend the complaint review if you want to.  You may come to our offices or be included by phone or video conference, if available. If you decide that you do not want to attend the complaint review, it will not affect our decision.

A committee of one or more Keystone First staff who has not been involved in the issue you filed your complaint about will review your complaint and make a decision. Your complaint will be decided no later than 30 days after we receive your complaint.  A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped and you file a complaint that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are not covered services or items for you, the service or items will continue until a decision is made.

What if I do not like Keystone First’s decision?

SECOND LEVEL COMPLAINT
If you do not agree with our first level complaint decision, you may file a second level complaint with Keystone First.

When should I file a second level complaint?

You must file your second level complaint within 45 days of the date you receive the first level complaint decision letter.

To file a second level complaint, you can:

  • Call Keystone First at 1-888-671-5276 and tell us your second level complaint, or
  • Write down your second level complaint and send it to us at:

Keystone First
Member Appeals Unit
200 Stevens Drive
Philadelphia, PA 19113-1570

What happens after I file a second level complaint?

You will receive a letter from Keystone First telling you that we have received your complaint, and telling you about the second level complaint review process.

You may ask Keystone First to see and ask for a copy of any information we have about your complaint. You may also send information to Keystone First that may help with your complaint.

You may attend the complaint review if you want to. You may come to our offices or be included by phone or video conference, if available. If you decide that you do not want to attend the complaint review, it will not affect our decision.

A committee made up of three or more people (including at least one person who is not an employee of Keystone First or of a related subsidiary or affiliate) who have not been involved in the issue you filed your complaint about, will review your complaint and make a decision. Your complaint will be decided no later than 45 days after we receive your complaint.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a second level complaint that is hand-delivered or postmarked within 10 days of the date on the first level complaint decision letter, the service or items will continue until a decision is made.

What can I do if I still do not like Keystone First's decision?

EXTERNAL COMPLAINT REVIEW
If you do not agree with Keystone First's second level complaint decision, you may ask for an external review by either the Department of Health or the Insurance Department.

The Department of Health handles complaints that involve the way a provider gives care or services. The Insurance Department reviews complaints that involve the Keystone First policies and procedures.

You must ask for an external review within 15 days of the date you received the second level complaint decision letter. If you ask, the Department of Health will help you put your complaint in writing.

You must send your request for external review in writing to either:

Pennsylvania Department of Health
Bureau of Managed Care
Room 912 Health and Welfare Building
625 Forster Street
Harrisburg, PA 17120-0701
1-888-466-2787
Fax (717) 705-0947
, or

Pennsylvania Insurance Department
Bureau of Consumer Services
1209 Strawberry Square
Harrisburg, PA 17120
1-877-881-6388

If you send your request for external review to the wrong department, it will be sent to the correct department.

The Department of Health or the Insurance Department will get your file from Keystone First. You may also send them any other information that may help with the external review of your complaint.

You may be represented by an attorney or another person during the external review.  A decision letter will be sent to you after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been receiving services or items that are being reduced, changed or stopped because they are not a covered service or items for you and you file a request for an external complaint review that is hand-delivered or postmarked within 10 days of the date on the second level complaint decision letter, the services or items will continue until a decision is made.