Grievance and Appeal Process

All of the staff at Providence PACE share the responsibility for making sure you are satisfied with the care that you receive from us. We encourage you to report any concerns at the time and place they occur. If you do not speak English, we will provide you with an interpreter. You may report a grievance using the following steps.

Reporting and Resolving Grievances 

Definition: A grievance is a verbal or written complaint about a problem you have with the services or the quality of care provided to you. A grievance can be a medical or non-medical concern.

1. Share your grievance with any Providence PACE staff member. Give complete information so that staff can take care of your grievance quickly. If you feel uncomfortable reporting your grievance you are encouraged to have a family member or caregiver speak on your behalf.
2. A Providence PACE staff member will coordinate an investigation and assign the appropriate staff member to look into your concern. 

Contact Information

• Phone: 206-320-5325
•  Fax: 206-320-5326

Unresolved Grievances 

1. If you are not satisfied with the grievance resolution you can take further action by notifying the Executive Director in writing of the reason for your dissatisfaction. You must send a letter to the Executive Director no later than 30 calendar days after the date of the final action taken on the grievance. Please send or deliver this letter to:
   Providence PACE Seattle
   Executive Director
   4515 Martin Luther King Jr. Way S. Ste. 100
   Seattle, WA 98108

2. The Executive Director will arrange a meeting of the committee responsible for grievances and monitoring participant satisfaction. You may be asked to meet with the committee if more information is needed to resolve the grievance.
3. Decisions will be reached in a timely manner. The Executive Director will notify you either verbally or in writing of the action, if any, that will be taken to address your grievance. If you are still unsatisfied with the resolution, the Executive Director will discuss other options available to you with assistance as needed. 

If at any time you are denied coverage or payment for a service you believe you are entitled to you may appeal using the Providence PACE appeals procedure described below.  Your family or caregiver may also appeal on your behalf.  If you do not speak English we will provide you with an interpreter for the appeals process.

Appeals Process 

Definition: An appeal is your action taken in response to any instance where Providence PACE denies or reduces coverage or payment for a service that you feel you are entitled to or you feel is medically necessary.

1. Notify Providence PACE in writing of your appeal within 30 calendar days of the initial denial.  You may also provide evidence related to your appeal in person or in writing.  Please send or deliver your appeal to:
   Providence PACE Seattle
   Executive Director
   4515 Martin Luther King Jr. Way S. Ste. 100
   Seattle, WA 98108
   
   Note: The 30-day limit may be extended for good cause.  Include in your request why you could not file the appeal within the 30-day time frame.
2. The Executive Director or another designated staff member will send you a letter verifying that your appeal has been received within 5 calendar days.
3. The Executive Director will have the appeal committee (which includes a third party who has no stake in the outcome of your appeal and was not involved in the initial decision you are appealing) review your appeal.
4. The appeal committee will resolve your appeal as quickly as your health condition requires but no later than 30 calendar days after your appeal was received.
5. During the appeals process Providence PACE will continue to provide you with all your services except for the service that is in dispute. For participants receiving Medicaid, Providence PACE will continue to provide the disputed service at your request until the final appeal decision is made. However, if your appeal is not made in your favor, you will have to pay for the costs of these disputed services.
6. If the third party makes a decision in the favor of:
   • You: Providence PACE will provide the disputed service as quickly as your health condition requires
   • Providence PACE: Providence PACE will notify the Centers for Medicare and Medicaid Services, the WA State Department of Social and Health Services, and you and/or your family, in writing, regarding the final denial of your appeal.  If you still disagree with the decision you have additional appeal rights under Medicare or Medicaid, but not both.  Providence PACE will inform you of these additional appeal rights in writing and assist you in the appropriate appeals process.

Expedited Appeals Process 

1. An expedited appeals process will be used when you believe that using the standard appeals process, without receiving your disputed service, could seriously harm your life, health or ability to regain maximum function.
2. Providence PACE will review the appeal as quickly as your health condition requires but no later than 72 hours after we receive your appeal.
3. Providence PACE may extend the 72-hour timeframe by up to 14 calendar days for any of the following reasons:
   • You request the extension
   • Providence PACE justifies to the WA State Department of Social and Health Services the need for additional information and how the delay is in your interest

Additional Appeal Rights

If you receive a wholly or partially adverse decision from Providence PACE and you disagree with this decision, you have additional appeal rights under Medicare or Medicaid, but not both.  Providence PACE will inform you of these additional appeal rights in writing and assist you in the appropriate appeals process.