Complaints and Appeals Process

Grievances/Appeals If you disagree with our benefit determination or feel that a decision has adversely affected your coverage, benefits, or relationship with Aspirus Health Plan, you can ask for a review of this decision by submitting a written grievance or appeal. If you have coverage under an individual or fully insured group plan, your written dissatisfaction is usually referred to as a “grievance.” If you are covered under a self-funded group plan, your written dissatisfaction with our benefit determination is usually referred to as an “appeal.” Please see your certificate, policy, or benefits booklet for a full description of the grievance and appeals procedures and your rights under state and/or federal law.

Our grievance and appeal process

  • If you are covered under a self-funded plan, your appeal must be submitted to us within 180 calendar days of the date you receive written notice of the adverse benefit determination as required by ERISA. You might have more time to appeal if your plan provides additional time.
  • If you are covered under an individual or fully insured group plan, please submit your grievance as soon as possible to the address listed below.
  • You have the right to submit written questions/comments, documents, records, evidence, testimony, and other information relating to the benefit decision in question.
  • A grievance/appeal must be submitted in writing unless the normal duration of the grievance/appeal process could have adverse effects on your health.
  • You may designate a representative to act for you by completing the Grievance Authorized Representative Form and sending it to us with your grievance/appeal.
  • You have the right to request, free of charge, access to and copies of all documents, records, and other information relevant to your grievance/appeal.
  • For decisions regarding medical judgment, we will consult with a health care professional with expertise in the relevant medical field.
  • You have the right to request, free of charge, the identity of any health care professional whose advice we obtained in connection with our decision.
  • We will acknowledge your grievance/appeal in writing within five business days of its receipt.
  • We will notify you in writing of the date your grievance/appeal will be heard at least seven calendar days before the meeting. You have the right to appear in person or to participate by teleconference in the grievance/appeal meeting to present information and/or ask questions.
  • For most grievances or appeals, we will notify you of our decision as soon as possible, but not later than 60 calendar days after our receipt of your grievance or appeal. However, we will notify you of our decision within 30 days of receiving your grievance or appeal if:
    - We had to approve coverage before you received care (i.e., prior authorization).
    - You have coverage under a fully insured plan and your grievance relates to coverage of experimental treatment.
  • If we are unable to notify you of our decision within the timeframes stated above, we will notify you in writing of the expected notification date and the reason for the delay.
  • If you or your physician feel that your life or health could be seriously jeopardized during the time it takes us to complete the grievance or appeal time frames described above, you can request an expedited grievance or urgent appeal. An expedited grievance or appeal will be handled as quickly as your health condition requires but no later than 72 hours from the time we receive your expedited grievance or appeal request.
  • An expedited grievance/appeal can be submitted by you or your physician either orally via telephone or in writing via mail or fax.

For all written grievances/appeals, please explain the specific reason(s) you disagree and submit copies of any supporting documentation to the following address, fax, or email address:

Aspirus Health Plan
Attn: Nondiscrimination Grievance Coordinator
PO Box 1890
Southampton, PA 18966

Fax Number: 763.847.4010 Email: G&A@AspirusHealthPlan.com If you have questions about the grievance/appeal process, or if you would like to submit an expedited grievance/appeal, you can call 866.631.5404 .

If we continue to deny payment, coverage, service requested, or if you do not receive a timely decision, you may be able to request an independent external review.

Non-Discrimination Grievance

The Non-Discrimination Grievance Form is available to you as a courtesy, and you are not required to complete it to submit a non-discrimination grievance. However, to begin the grievance process, we do need a written explanation of the problem. Please complete this form and return it to us.

Non-Discrimination Grievance Form (PDF)

Non-Discrimination Policy (PDF)

Grievance Authorized Representative Form (PDF)