UPMC/Highmark Complaint Form stayinformed@attorneygeneral.gov Health Care Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 1-844-743-2015 1-717-705-6938 1-717-787-1190 (fax) www.attorneygeneral.gov WHEN SHOULD YOU FILE A COMPLAINT? If you are unable to resolve a health-related complaint directly with the person or company you are complaining against, then you should file a complaint with the Office of Attorney General, Health Care Section (HCS), by completing a complaint form and medical release authorization. If your complaint is against your insurance company, then you should refer to your contract to ensure that you have taken all the appropriate steps to file a complaint or grievance directly with the Plan. Filing a complaint with the HCS does not preserve your appeal rights; therefore, you are encouraged to file an appeal with your insurance company while simultaneously filing a complaint with the HCS. The completed forms and any supporting documentation should be mailed to the address below or sent via email to stayinformed@attorneygeneral.gov. Office of Attorney General Health Care Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 HOW CAN YOU EXPEDITE THE PROCESSING OF YOUR COMPLAINT? Complete all portions of the complaint form that apply to your situation Describe what actions you have taken to resolve your complaint State what action you are seeking in order to resolve your complaint Include any supporting documentation that further explains your complaint and your position for resolving the complaint WHAT SHOULD YOU EXPECT AFTER YOU FILE A COMPLAINT? Your complaint will be reviewed to determine if the HCS is the most appropriate agency to address your concerns. Upon receipt of your complaint, the HCS will send you an acknowledgment letter: 1. 2. Providing your file number and assigned Agent; or Advising that your complaint has been forwarded to another state or federal agency for handling. If your complaint is assigned to an Agent, then your Agent will forward a copy of your complaint (as submitted) to the person or company you are complaining against and request a response to the complaint within 15 business days. Your Agent will forward you a copy of the response to your complaint and will keep you informed of any new developments in your case. Please allow your Agent a minimum of 30 days to contact you with an update on your file. American LegalNet, Inc. www.FormsWorkFlow.com UPMC/Highmark Complaint Form stayinformed@attorneygeneral.gov Health Care Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 1-844-743-2015 1-717-705-6938 1-717-787-1190 (fax) Required fields are marked with an asterisk* Your information: Age Group: Are you a veteran? Are you on active duty? Yes Yes Name* No No Under 18 18-34 35-59 60-64 65 and older www.attorneygeneral.gov Mr. Mrs. Address* Ms. Dr. City* State* Zip Code* County* Daytime Phone Number* ( ) Home Phone Number* ( ) Email Address If completing this form on behalf of someone else, please complete the following information: Age Group: Are they a veteran? Are they on active duty? Yes Yes No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name* City* State* Zip Code* County* Daytime Phone Number ( ) Home Phone Number ( ) Email Address Who is the complaint against? Insurance Information: Insurance Company UPMC Highmark Both Subscriber's Name Policy No. Group No. Patient's Name Patient's Date of Birth Patient's Relationship to Subscriber Type of Insurance: (Please check) HMO PPO POS Traditional Medicare Medical Assistance Other ________________________ American LegalNet, Inc. www.FormsWorkFlow.com Filing a complaint with the Office of Attorney General does not preserve your appeal rights pursuant to your insurance contract or any applicable laws. To preserve your rights you must file an appeal (complaint or grievance) directly with your health insurer/administrator in conformance with the terms of your coverage. Please briefly explain your complaint. Tell WHAT happened, WHEN it happened, and WHERE it happened. Describe the events in the order in which they happened. ATTACH COPIES of all applicable insurance contracts or policies, medical bills, explanations of benefits, correspondence, receipts, cancelled checks (front & back), advertisements or any other papers that relate to your complaint. Please complete and sign the attached "Authorization to Release Medical/Insurance Records." PLEASE TYPE or PRINT your explanation. If additional space is needed, please use additional paper and attach to complaint form. What specific resolution are you seeking in order to settle your complaint? American LegalNet, Inc. www.FormsWorkFlow.com In order to fully evaluate your complaint, we will need you to answer the following questions. If you need more space, please attach additional pages. 1. Do you have Highmark Insurance? ___ Yes 2. ___ No Are you attempting to access a UPMC doctor(s)? ___ Yes ___ No a. If your answer was yes to question #2, please provide the following: i. Name of the doctor(s)__________________________________________________________ _________________________________________________________________ _________________________________________________________________ ii. Name of the practice(s) including address(es) and phone number(s) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ iii. Reason why you are visiting this (these) doctor(s) _________________________________________________________________ 3. Are you trying to access a UPMC facility? ___ Yes ___ No a. If so, which facility? _______________________________________________________ 4. Is the care you are seeking related to a prior or ongoing underlying medical condition? ___ Yes ___ No a. If so, what is the original condition? __________________________________________ 5. Have you seen a UPMC doctor(s) in the past for this issue or a related issue? a. If so, when? _____________________________________________________________ b. Please provide the name(s) of the doctor(s) and the treatment you received. ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________