Kentucky Medicaid Mco Member Grievance Form

Download a blank fillable Kentucky Medicaid Mco Member Grievance Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Kentucky Medicaid Mco Member Grievance Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Member Grievance –MCO 012016
Kentucky Medicaid MCO
Member Grievance Form
MCO
Phone
Fax
 Anthem BCBS Medicaid
1-855-661-3027 Ext. 26748
1-855-443-7820
Check the box of
the plan in which
 Coventry Cares/Aetna Better Health
1-855-300-5528
1-855-454-5585
the member is
 Humana – CareSource
1-877-892-7487
1-855-262-9194
enrolled
 Passport Health Plan
1-800-578-0603
502-585-8340
 WellCare of Kentucky
1-877-389-9457
1-866-388-1769
Please complete all appropriate fields
If you need assistance with this form, call your MCO at the number listed above
All Grievances must be filed within 30 days from the date of MCO action
Date _______________________
Person filing grievance _______________________________ Email ______________________________ Phone _______________
 I am a Medicaid member  I am filing a grievance on behalf of a Medicaid member
If filing on behalf of member, state relationship to member ________________________________________________
Who is the Grievance/Complaint about?
Member’s name ________________________________ _______________________________ ___________________
Member’s SSN ________________________________
_ Member’s Date of Birth ____________
___________________
Member’s address ______________________________ _______________________________ County _____________
What is the Grievance/Complaint about?
 I am having trouble finding a healthcare provider
 I have a complaint about my doctor/healthcare provider
 I have a complaint about my facility and/or its staff (Nursing, Assisted Living, Adult Family Care Home, Hospice)
 I am receiving bills from healthcare providers
 I want to change my plan and need help
 I am a new member and have not received any plan information
 I am having trouble obtaining the following prescriptions: ______________________________ _________________
 I am having trouble obtaining the following service: (Check all that apply)
 Behavioral Health
 De
ntal
 Home Health
 Medical Equipment/Supplies
 Transportation
 Substance Abuse Treatment
 Occupational/Physical/Speech Therapy
 Other_______________________________________
Please give as much detail as possible about this complaint/grievance:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
 By signing this document, I authorize the person submitting this form to do so on my behalf
Signature of Member ____________________________ _______________________________ Date _______________
Signature of person filing grievance ________________ _______________________________ Date _______________
This form complies with the Grievance process as outlined in KAR 17:010

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Kentucky Medicaid Mco Member Appeal Request Form Kentucky Medicaid Mco Member Appeal Request Form Medical
Kentucky Medicaid Mco Prior Authorization Request Form Kentucky Medicaid Mco Prior Authorization Request Form Business
Form Map-529 - Kentucky Medicaid Change Of Information Form Form Map-529 - Kentucky Medicaid Change Of Information Form Legal
California Managed Care Members Grievance Form California Managed Care Members Grievance Form Business
Anthem Blue Cross Member Grievance Form Anthem Blue Cross Member Grievance Form Business
Form 3160-0019 - Formal Grievance Form Form 3160-0019 - Formal Grievance Form Legal
Form C-5321 - Member Claim Form Form C-5321 - Member Claim Form Business
Form C-3344 - Member Claim Form Form C-3344 - Member Claim Form Business
Form Wp 11371 - Member Contribution Form Form Wp 11371 - Member Contribution Form Financial
Kentucky Aarp Speaker / Booth Request Form Kentucky Aarp Speaker / Booth Request Form Medical

Related Categories

Parent category: Business
Download
Go