Grievance and Appeals
Filing an Appeal
There may be times when Peach State Health Plan will not pay for services that have been recommended by your doctor. If we do this, a letter will be mailed to you and your provider for services that are not approved. This letter is called an Adverse Benefit Determination letter.
An Adverse Benefit Determination is when Peach State Health Plan:
- Denies the care you want.
- Decreases the amount of care.
- Ends care that has already been approved.
- Denies payment for care. You may have to pay for it.
The adverse benefit determination will explain how you or your doctor (with your consent) or a legal representative of a deceased member’s estate can ask for an appeal of the decision.
The Appeal Process includes Step 1 which is an Appeal and Step 2 which is an Administrative Law Hearing (Medicaid members) or Formal Appeal Process (PeachCare for Kids® members).
Filing a Grievance
We hope our members will always be happy with us and our providers. But if you are not happy, please let us know. This includes if you do not agree with a decision your provider has made about your care. A grievance is an expression of dissatisfaction about any matter other than an Adverse Benefit Determination.
A Member Grievance can be filed if or when:
- A Member is dissatisfied with a provider services or care
- Provider and/or staff have behavior that is inappropriate or discourteous
- Provider has limited availability to members
- Your appeal was not processed timely