Prime Remote Handbook

A grievance is a written complaint or concern about a non-appealable issue regarding a perceived failure by any member of the health care delivery team—including TRICARE-authorized providers, military providers, regional contractors, or subcontractor personnel—to provide appropriate and timely health care services, access or quality, or to deliver the proper level of care or service.

The grievance process allows full opportunity to report in writing any concern or complaint regarding health care quality or service. Any TRICARE civilian or military provider, TRICARE beneficiary, sponsor, parent or guardian, or other representative of an eligible dependent child may file a grievance. Humana Military is responsible for the investigation and resolution of all grievances. Grievances are resolved no later than 60 days from receipt. Following resolution, the party who submitted the grievance will be notified of the review completion.

Grievances may include such issues as:
   

• The quality of health care or service aspects such as accessibility, appropriateness, level, continuity, or timeliness of care
• The demeanor or behavior of providers and their staff
• The performance of any part of the health care delivery system
• Practices related to patient safety

• The beneficiary’s name, address, and telephone number
• Sponsor’s Social Security number
• Beneficiary’s date of birth
• Beneficiary’s signature
• A description of the issue or concern must include:
  • The date and time of the event
  • Name of the provider(s) and/or person(s) involved
  • Location of the event (address)
  • The nature of the concern or complaint
  • Details describing the event or issue
  • Any appropriate supporting documents

Figure 7.4

     
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