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 health care or service you receive.

Some examples of a formal grievance are:

  • If you have a problem with the quality of care or services you have received.
  • If a provider or our employee was rude to you.
  • If you feel a provider or one of our employees did not respect your rights as a member of our plan.

What should I do if I have a formal grievance? 

To file a formal grievance, you or your representative should put the problem in writing.  You can also download and fill out a Member Grievance Form (PDF)Here are the things you should include:

  • Who is involved in the grievance?
  • What happened?
  • When did it happen?
  • Where did it happen?
  • Why are you not happy with the health care you received?

You may attach any documents that will help us look into the problem.  If you need us to, we will help you file a grievance.  You may call Member Services for assistance in filing your formal grievance.  You can send your completed Member Grievance Form or letter to us at: 

West Virginia Family Health
PO Box 22250
Pittsburgh, PA  15222

When should I file a formal grievance? 

You, or your representative, must file your formal grievance within 1 year from the date the problem happened or 90 days from the date you received the informal grievance decision letter. 

What happens after I file a formal grievance? 

After you, or your representative, file a formal grievance, you will get a letter from us within 5 working days.  This letter will tell you that we have received your grievance.  It will also include information about the formal grievance review process.  You may appoint a representative to act on your behalf.  You or your representative may submit additional information.  You or your representative may review all documentation regarding the grievance upon request free of charge.  You may also choose to meet with us in person at our office location or a location convenient to you.

One of our staff members, who has not been involved but knows the most about your issue, will review your formal grievance and make a decision within 45 days after we receive your formal grievance.

You or your representative may extend the timeframe for decision of the formal grievance up to 14 days.  We may also extend the timeframe for decision of the formal grievance up to 14 days if additional information is necessary and the delay is in your interest.  If we extend the timeframe, we will send you a written notice of the reason for the delay.

A decision letter will be mailed to you after the decision is made.  This letter will tell you the reason or reasons for the decision.

What if I don’t like WVFH’s decision about my formal grievance?

If you do not agree with our decision, you, or your representative, may ask for a State Fair Hearing.  You may also file an appeal with the West Virginia Office of the Insurance Commissioner, when appropriate.

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.