Inquiry & Appeal Process

Standard Inquiry and Complaint Resolution Process

Preferred Choices honors any inquiry, complaint or reconsideration request relating to the Preferred Choices provider network. This includes telephone, written, electronic (e-mail and fax) inquiries. Upon receipt of an inquiry, Preferred Choices will review the inquiry or request and provide a response based on established customer resolution standards as indicated below.

• All member inquiries will be handled by the Preferred Choices Customer Service department which can be reached at 1-800-992-6837.
• Electronic inquiries via e-mail will receive an initial e-mail confirmation. Where possible, a verbal response will be provided to ensure the security of information relayed over the Internet.
• Preferred Choices investigates and notifies the member of the outcome for provider network complaints within three (3) business days. Complaints requiring investigation will be completed within thirty (30) calendar days of receipt. The member will be given a response that describes Preferred Choices decision and explains further review rights.
• When requested by the member, Preferred Choices will allow a member representative to act on the member’s behalf. To protect member confidentiality, this requires written confirmation from the member.
• As appropriate, the member will be redirected to the Third Party Administrator or the Utilization Management organization for inquiries, which are not handled by Preferred Choices. (Examples include: benefit questions, questions about payment of claims, questions about pre-certification requirements, authorizations, case management, health care or denials of service).

Expedited Inquiry and Complaint Resolution Process

The member may also request an expedited review by Preferred Choices involving a provider network issue, if clinically urgent. Clinically urgent appeals will be investigated and decision made within three (3) working days of receipt of the member inquiry or complaint.