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					      INSTRUCTIONS FOR COMPLETING THE GRIEVANCE REPORT
Each Quarterly Report is due to the Agency no later than 45 calendar days
following the end of the reporting period. Example: the 1st Quarter Report is due to
the Agency no later than 45 calendar days from March 31.

On the 1st Quarter Report ONLY -
Insert the   PDHP Medicaid Provider Number: , the                      PDHP Name:         and the         Fiscal Year:
This information will carry over into the 2nd, 3rd, and 4th Quarter report templates automatically.

Provide the following information on ALL the Quarter templates:

         Recipient Information
Medicaid ID # - Provide the 7 digit Medicaid ID number for the PDHP member.
Last Name - Provide the Medicaid member's last name
First Name - Provide the Medicaid member's first name
MdlInt. - Provide the Medicaid member's middle initial

               Grievance Information
Treating Provider's License # - Provide the treating provider's professional practice license number.
Date of Grievance - Provide the date the grievance was received by the PDHP
Expedited Request - Yes/No - Answer Y for yes or N for no.
(1-13) Type of Grievance - Using the categorized types of grievances provided at the top of the template,
           choose the appropriate type of grievance numbered 1 - 13. Type in only the corresponding
           number associated with the grievance type, Example: 7. This would indicate that the
           grievance was filed because of a potential member's rights violation.
Date of Disposition - Provide the date that the plan reached its decision for adjudication of the grievance.
Date of Disposition - Using the categorized types of dispostions provided at the top of the template,
           choose the appropriate type of disposition numbered 1 - 13. Type in only the corresponding
           number associated with the disposition type, Example: 7. This would indicate that the
           grievance was being handled by a PDHP QA review.
Resolved, Unresolved - Indicates whether or not the case was resolved during the reporting period. Use 'R' for
           resolved cases and 'U' for unresolved, i.e., still pending disposition or under review. Any unresolved
           grievances must be carried over and reported on the next quarterly report.
Other: Explanation - Use this column ONLY if the type of grievance or disposition is not listed in the 1 - 13
           types at the top of the template. A brief explanation is required whenever this field is used.
Total Days Open - This is a self calculating field that, using the date of the grievance and the date of the
           disposition will calculate the number of days the grievance was unresolved or under review
  Grievance Types:                                                         Disposition Types:
  1. Quality of Care              8. Enrollment/Disenrollment              1. Referral made to specialist    8. In PDHP Grievance Process
  2. Access to Care               9. Services after Termination            2. PCDP Appointment made          9. Referred to Area Office
  3. Emergency Services           10. Unauthorized out-of-plan serv.       3. Bill Paid                      10. Lost contact with member
  4. Not Medically Necessary      11. Unauthorized in plan services        4. Procedure Scheduled            11. Hospitalized/Institutionalized
  5. Benefit Dispute              12. Experimental/Investigational         5. Reassigned PCDP                12. Confirmed original decision
  6. Billing Dispute              13. Other - provide explanation          6. Disenrolled Self               13. Other - provide explanation
  7. Member's Rights Violation                                             7. In PDHP QA Review
            1st Quarter Report                                                                                                                      Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                                                   Total Unresolved Complaints        0
PDHP Name:                                                                                                                                                   Total Complaints        0
Fiscal Year:
                    Recipient Information                                                              Grievance Information                R=
                                                                           Treating            Expedited (1-13)                (1-13)    Resolved                               Total #
   Medicaid          Last                       First                  Mdl Provider's  Date of  Request Type of   Date of     Type of       U=      Other:                      Days
    ID#:            Name:                      Name:                   Int. License # Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation                 Open
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          1st Quarter Report                                                                                               Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                          Total Unresolved Complaints        0
PDHP Name:                                                                                                                          Total Complaints        0
Fiscal Year:
                    Recipient Information                                Grievance Information                       R=
                                                    Treating            Expedited (1-13)                (1-13)    Resolved                             Total #
   Medicaid          Last               First   Mdl Provider's  Date of  Request Type of   Date of     Type of       U=      Other:                    Days
    ID#:            Name:              Name:    Int. License # Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation               Open
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          1st Quarter Report                                                                                               Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                          Total Unresolved Complaints        0
PDHP Name:                                                                                                                          Total Complaints        0
Fiscal Year:
                    Recipient Information                                Grievance Information                       R=
                                                    Treating            Expedited (1-13)                (1-13)    Resolved                             Total #
   Medicaid          Last               First   Mdl Provider's  Date of  Request Type of   Date of     Type of       U=      Other:                    Days
    ID#:            Name:              Name:    Int. License # Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation               Open
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 Grievance Types:                                                           Disposition Types:
 1. Quality of Care                8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
 2. Access to Care                 9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
 3. Emergency Services             10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
 4. Not Medically Necessary        11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
 5. Benefit Dispute                12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
 6. Billing Dispute                13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
 7. Member's Rights Violation                                               7. In PDHP QA Review
            2nd Quarter Report                                                                                                                      Total Resolved Complaints        0
  PDHP Medicaid Provider Number:                                                                                                                  Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                                                 Total Complaints        0
Fiscal Year:
                      Recipent Information                                                       Grievance Information                       R=
                                                                             Treating           Expedited (1-14)                (1-13)    Resolved                              Total #
  Medicaid            Last                        First                 Mdl Provider's  Date of Request Type of    Date of     Type of       U=     Other                       Days
   ID#:              Name:                       Name:                  Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                 Open
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          2nd Quarter Report                                                                                                  Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                             Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                           Total Complaints        0
Fiscal Year:
                      Recipent Information                                  Grievance Information                      R=
                                                       Treating           Expedited (1-14)                (1-13)    Resolved                              Total #
  Medicaid            Last                First   Mdl Provider's  Date of Request Type of    Date of     Type of       U=     Other                       Days
   ID#:              Name:               Name:    Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                 Open
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          2nd Quarter Report                                                                                                  Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                             Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                           Total Complaints        0
Fiscal Year:
                      Recipent Information                                  Grievance Information                      R=
                                                       Treating           Expedited (1-14)                (1-13)    Resolved                              Total #
  Medicaid            Last                First   Mdl Provider's  Date of Request Type of    Date of     Type of       U=     Other                       Days
   ID#:              Name:               Name:    Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                 Open
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 Grievance Types:                                                          Disposition Types:
 1. Quality of Care               8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
 2. Access to Care                9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
 3. Emergency Services            10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
 4. Not Medically Necessary       11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
 5. Benefit Dispute               12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
 6. Billing Dispute               13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
 7. Member's Rights Violation                                              7. In PDHP QA Review
            3rd Quarter Report                                                                                                                       Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                                                    Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                                                  Total Complaints        0
Fiscal Year:
                    Recipient Information                                                        Grievance Information                      R=
                                                                           Treating             Expedited (1-14)               (1-13)    Resolved                                Total #
  Medicaid           Last                        First                 Mdl Provider's  Date of   Request Type of  Date of     Type of       U=     Other:                        Days
   ID#:             Name:                       Name:                  Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                   Open
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 Grievance Types:                                                          Disposition Types:
 1. Quality of Care               8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
 2. Access to Care                9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
 3. Emergency Services            10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
 4. Not Medically Necessary       11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
 5. Benefit Dispute               12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
 6. Billing Dispute               13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
 7. Member's Rights Violation                                              7. In PDHP QA Review
            3rd Quarter Report                                                                                                                       Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                                                    Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                                                  Total Complaints        0
Fiscal Year:
                    Recipient Information                                                        Grievance Information                      R=
                                                                           Treating             Expedited (1-14)               (1-13)    Resolved                                Total #
  Medicaid           Last                        First                 Mdl Provider's  Date of   Request Type of  Date of     Type of       U=     Other:                        Days
   ID#:             Name:                       Name:                  Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                   Open
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 Grievance Types:                                                          Disposition Types:
 1. Quality of Care               8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
 2. Access to Care                9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
 3. Emergency Services            10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
 4. Not Medically Necessary       11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
 5. Benefit Dispute               12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
 6. Billing Dispute               13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
 7. Member's Rights Violation                                              7. In PDHP QA Review
            3rd Quarter Report                                                                                                                       Total Resolved Complaints        0
 PDHP Medicaid Provider Number:                                                                                                                    Total Unresolved Complaints        0
PDHP Name: 0                                                                                                                                                  Total Complaints        0
Fiscal Year:
                    Recipient Information                                                        Grievance Information                      R=
                                                                           Treating             Expedited (1-14)               (1-13)    Resolved                                Total #
  Medicaid           Last                        First                 Mdl Provider's  Date of   Request Type of  Date of     Type of       U=     Other:                        Days
   ID#:             Name:                       Name:                  Int. License # Grievance Yes/No Grievance Disposition Disposition UnresolvedExplanation                   Open
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  Grievance Types:                                                      Disposition Types:
  1. Quality of Care           8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
  2. Access to Care            9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
  3. Emergency Services        10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
  4. Not Medically Necessary   11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
  5. Benefit Dispute           12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
  6. Billing Dispute           13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
  7. Member's Rights Violation                                          7. In PDHP QA Review
          4th Quarter Report                                                                                                                             Total Resolved Complaints         0
PDHP Medicaid Provider Number:                                                                                                                         Total Unresolved Complaints         0
PDHP Name: 0                                                                                                                                                      Total Complaints         0
 Fiscal Year:
                     Recipient Information                                                      Grievance Information                      R=
                                                                         Treating              Expedited (1-14)               (1-13)    Resolved                                     Total #
  Medicaid           Last                      First                Mdl Provider      Date of   Request Type of  Date of     Type of       U=      Other:                            Days
   ID#:             Name:                     Name:                 Int. License#    Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation                       Open
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  Grievance Types:                                                      Disposition Types:
  1. Quality of Care           8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
  2. Access to Care            9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
  3. Emergency Services        10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
  4. Not Medically Necessary   11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
  5. Benefit Dispute           12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
  6. Billing Dispute           13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
  7. Member's Rights Violation                                          7. In PDHP QA Review
          4th Quarter Report                                                                                                                             Total Resolved Complaints         0
PDHP Medicaid Provider Number:                                                                                                                         Total Unresolved Complaints         0
PDHP Name: 0                                                                                                                                                      Total Complaints         0
 Fiscal Year:
                     Recipient Information                                                      Grievance Information                      R=
                                                                         Treating              Expedited (1-14)               (1-13)    Resolved                                     Total #
  Medicaid           Last                      First                Mdl Provider      Date of   Request Type of  Date of     Type of       U=      Other:                            Days
   ID#:             Name:                     Name:                 Int. License#    Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation                       Open
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  Grievance Types:                                                      Disposition Types:
  1. Quality of Care           8. Enrollment/Disenrollment              1. Referral made to specialist   8. In PDHP Grievance Process
  2. Access to Care            9. Services after Termination            2. PCDP Appointment made         9. Referred to Area Office
  3. Emergency Services        10. Unauthorized out-of-plan serv.       3. Bill Paid                     10. Lost contact with member
  4. Not Medically Necessary   11. Unauthorized in plan services        4. Procedure Scheduled           11. Hospitalized/Institutionalized
  5. Benefit Dispute           12. Experimental/Investigational         5. Reassigned PCDP               12. Confirmed original decision
  6. Billing Dispute           13. Other - provide explanation          6. Disenrolled Self              13. Other - provide explanation
  7. Member's Rights Violation                                          7. In PDHP QA Review
          4th Quarter Report                                                                                                                             Total Resolved Complaints         0
PDHP Medicaid Provider Number:                                                                                                                         Total Unresolved Complaints         0
PDHP Name: 0                                                                                                                                                      Total Complaints         0
 Fiscal Year:
                     Recipient Information                                                      Grievance Information                      R=
                                                                         Treating              Expedited (1-14)               (1-13)    Resolved                                     Total #
  Medicaid           Last                      First                Mdl Provider      Date of   Request Type of  Date of     Type of       U=      Other:                            Days
   ID#:             Name:                     Name:                 Int. License#    Grievance Yes/No Grievance Disposition Disposition Unresolved Explanation                       Open
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DOCUMENT INFO
Description: Examples of Contract document sample