What can I do if my health is at immediate risk?
Expedited complaints and grievances
If your doctor or dentist believes that the usual timeframes for deciding your complaint or grievance will harm your health, you or your doctor or dentist can call Keystone First at 1-800-521-6860 and ask that your complaint or grievance be decided faster. You will need to have a letter from your doctor or dentist faxed to 1-215-937-5367 explaining how the usual timeframe for deciding your complaint or grievance will harm your health.
If your doctor or dentist does not fax Keystone First this letter, your complaint or grievance will be decided within the usual timeframes.
Expedited complaint
The expedited complaint will be decided by a licensed doctor, who has not been involved in the issue you filed your complaint about. Keystone First will call you within 48 hours of when we receive your provider's letter explaining how the usual timeframe for deciding your complaint will harm your health or 3 business days of when we receive your request for an expedited (faster) complaint review with our decision, whichever is shorter. You will also receive a letter telling you the reason(s) for the decision and how to file a second level complaint, if you do not like the decision.
An expedited complaint decision may not be requested after a second level complaint decision has been made on the same issue.
Expedited grievance and expedited external grievance
A committee of three or more people, including a licensed doctor, will review your grievance. The licensed doctor will decide your expedited grievance with help from the other people on the committee. No one on the committee will have been involved in the issue you filed your grievance about.
Keystone First will call you within 48 hours of when we receive your provider's letter explaining how the usual timeframe for deciding your grievance will harm your health or 3 business days of when we receive your request for an expedited (faster) grievance review with our decision, which ever is shorter. You will also receive a letter telling you the reason(s) for the decision and that you can ask for an expedited external grievance review, if you do not like the decision.
If you want to ask for an expedited external grievance review by the Department of Health, you must call Keystone First at 1-800-521-6860 within 2 business days from the date you get the expedited grievance decision letter. Keystone First will send your request to the Department of Health within 24 hours after receiving it.
An expedited grievance decision may not be requested after a second level grievance decision has been made on the same issue.
What kind of help can I have with the complaint and grievance processes?
If you need help filing your complaint or grievance, a staff member from Keystone First will help you. This person can also represent you during the complaint or grievance process. You do not have to pay for the help of a staff member.
This staff member will not have been involved in any decision about your complaint or grievance.
You may also have a family member, friend, lawyer or other person help you file your complaint or grievance. This person can also help you if you decide you want to appear at the complaint or grievance review. For legal assistance you can contact Legal Aid at 1-800-322-7572.
At any time during the complaint or grievance process, you can have someone you know represent you or act on your behalf. If you decide to have someone represent or act for you, tell Keystone First, in writing, the name of that person and how we can reach him or her.
You or the person you choose to represent you may ask Keystone First to see and ask for a copy of any information we have about your complaint or grievance.