This form is to gather information about problems and concerns with HMOs. It is not part of the HMO or state complaint process. If you have a problem and your HMO does not correct it, you should file a grievance with your HMO or the state. Check your member handbook or call your HMO to determine how to file a grievance. If you need help, Legal Services may be able to provide free legal assistance.
This form is being completed by: Consumer | Provider/Physician | Agency | Advocate
Patient is insured by: Medicaid | Medicare | Private
Name of HMO:________________________________
Please check all categories that apply.
Treatment or Coverage
o HMO says service is not medically necessary
o HMO says service is not covered by plan
o Questions not answered by provider/plan
o Other:_____________________________
Payment
o Payment denied for emergency services
o Payment denied for non-emergency services
o Payment denied because not preauthorized
o Payment delayed
o Inadequate payment
o Other:_____________________________
Transportation
o Provider is too far away
o HMO does not provide transportation
o Other:_____________________________
Access
o Cannot get appointment
o Cannot see provider of choice
o Trouble getting to see specialist
o Trouble getting medicine
o Trouble getting help nights or weekends
o Wait too long in office
o Language or cultural problems
o Other:_____________________________
Information/Marketing
o Enrollment counseling problems
o Direct marketing by HMO
o Fraud
o Questions not answered by HMO
o Questions not answered by DSS
o Information is wrong or incomplete
o Other:_____________________________
Comments:____________________________________
Have you tried to solve this problem? How? What happened?
Optional
Your name:_______________________________________________________________
Agency or organization (if applicable):____________________________________________
Address:__________________________________________________________________
Phone:____________________________________________________________________
Please return to: This form was developed by Ohio State Legal Services Association and UHCAN Ohio (Universal Health Care Action Network Ohio), with modifications by the National Health Law Program. The form can be made returnable to legal services offices, consumer advocacy organizations, or the state Medicaid agency to gather information about problems and concerns with HMOs.
July 14, 1997
