How does PacificSource handle grievances and appeals?

We classify concerns received from our members in the following ways: • Concern means any expression—written or verbal—of dissatisfaction with PacificSource. €¢ Inquiry means a written request for information or clarification about any matter related to a member’s health plan. An inquiry is not a complaint or grievance.

€¢ Complaint means an expression of dissatisfaction about a specific problem encountered by a member, treatment by a provider, or decision made by PacificSource. A complaint must include a request for action to resolve the problem or change the decision. Grievances and appeals fall under this category.

For concerns, inquiries, and complaints, we follow an informal review process, especially if the issue can be resolved fairly easily. If a member’s complaint is identified as either a grievance or an appeal (typically when it’s formally written that way), we follow what’s called a formal review to determine how it can be resolved. The form your communication takes—written ... more.

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