Grievances & Appeals

Informal Grievances

An informal grievance is a verbal expression of unhappiness.  This is a way for you, or someone you choose, to tell us when you are not happy with something.

Read more about informal grievances.
 

Formal Grievances

A formal grievance is a written expression of dissatisfaction.  You can file a formal grievance if you have a problem with the quality of healthcare or service you receive.

Read more about formal grievances.
 

Appeals

An appeal is a request for a review of our action to deny or limit authorization or payment for healthcare services.

Read more about appeals.
 

Dental Grievances and Appeals

If you want to submit an appeal or file a complaint related to children’s dental services, call Scion Dental at 1-855-434-9237.

Provider Appeals

There are two types of Provider Appeals. 

Provider Disputes are requests that are not regarding medical necessity rather are administrative in nature such as, but not limited to, disputes regarding the amount paid, appeals of denials regarding lack of modifiers, refunded claim payments due to incorrect payment or coordination of benefit issues.

Clinical Provider Appeals  are cases that are denied due to lack of prior authorization or denied based on medical necessity.

To submit a Provider Dispute, please use this contact information below.

1.      Send us a request by fax to:

·         All Providers: 1-844-207-0334

2.      Mail in a request to:

·         Non-Participating Medicare Provider, and any Pre-Service Appeals:

WVFH
Attn: Claims Review
444 Liberty Avenue, Suite 2100
Pittsburgh, PA 15222

To submit a Clinical Provider Appeal, please use this contact information below.

       1.      Send us a request by fax to:

·         All Member Appeals or Grievances Appeals: 412-255-4503

·         All Medicaid Providers: 855-501-3904

2.      Mail in a request to:

·         All Medicaid Providers:

WVFH
Attn: Clinical Provider Appeals
P.O. Box 22278
Pittsburgh, PA 15222