ADMINISTRATIVE COMPLAINTS
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An administrative complaint is any complaint relevant to a provider, a governmental entity, an institution, or a Managed Care Organization that anyone other than a member presents, either in written or verbal form. An Administrative Complaint is not a request for a retro-authorization of service or a re-determination of payment. An Administrative Complaint may not be initiated by a member.

Administrative complaints may be initiated either by telephone on the toll-free provider line at 877-615-8503 or in writing addressed to:

Administrative complaints may also be faxed to 724-744-6363.

VBH-PA will document and work to resolve all administrative complaints within fifteen (15) business days of receipt.  If a complaint cannot be handled at the first point of contact, one of the Complaint Quality Analysts will assign the complaint to the appropriate staff to resolve the complaint in an expedient manner.  A letter outlining the resolution of the initial complaint will be sent to the complainant when the resolution of the complaint is accomplished, or within five (5) business days after the initial fifteen (15) business days allocated for the complaint resolution, whichever comes first.

If the complainant is not satisfied with the initial resolution, s/he may file an appeal within five (5) business days of the receipt of the initial complaint resolution letter.  The appeal may be initiated either by telephone on the toll-free provider line (877-615-8503) or in writing addressed to the address above.  Appeals of initial complaint resolutions will be reviewed by the Complaint Appeals Committee within thirty (30) calendar days of receipt of the appeal request by one of the Complaint Quality Analysts.  The Complaint Appeals Committee will be made up of the Director of Member and Provider Services, one of the Complaint Quality Analysts, a representative from the VBH-PA Quality Management Department, a member of VBH-PA Senior Management or an Account Executive, and a VBH-PA Provider Field Coordinator.  If the complaint involves an issue or issues concerning services rendered to a HealthChoices member, the Administrator or Administrator designee from the member’s county of residence will be invited to participate on the Complaint Appeals Committee. 

The Complainant will be notified of the date and time of the Complaint Appeals Committee meeting by certified mail at least ten (10) calendar days in advance of the meeting.  The Complainant will be given the opportunity to appear before the Committee for the first thirty (30) minutes of the meeting, should they so choose.  Any and all individuals accompanying the Complainant at this appearance must be prior approved by the Committee.

The decision of the Complaint Appeals Committee will be rendered in writing within five (5) business days.  The decision of the Complaint Appeals Committee is final.

All administrative complaints will be tracked by one of the Complaint Quality Analysts and trended for quality management.