A written complaint or concern regarding a medical practitioner, TAMS, or the Nova Pathfinder Healthcare program, in general, is referred to as a grievance. Grievances are distinct from authorization appeals, claims appeals, and claim review problems. Here are some examples of grievances:
- Quality of services provided by a provider (inadequate service, ineffective care, inaccurate results)
- Providers’ conduct or actions and their Inaccurate personnel information
- Delays or mistakes in the processing of authorizations
- Patient protection issues at a hospital or doctor’s office
- Privacy issues
Note: Disputing charges for services should not be submitted as a grievance.
Who can file a Grievance?
Anyone can file a grievance. However, if the grievance is about someone other than the person who filed the grievance, Nova Pathfinder may not be able to give a full response without an Authorization for Disclosure of Medical or Dental Information form on file; this generally applies to spouses and parents of adult children submitting grievances about their spouse or adult child.
What is the Grievance Process?
Nova Pathfinder Healthcare takes complaints seriously. We will conduct a thorough investigation of the concerns and take actions as necessary to improve services. If necessary, we will contact the involved provider(s) and various Nova Pathfinder departments to gather additional information. Generally, we do not contact the Member unless the information in the grievance is unclear. The person who submitted the grievance will receive a written response, usually within 60 days.
How is a grievance submitted?
Print a Nova Pathfinder Limited Healthcare Grievance Form or send a letter with the following:
- Name, address, and telephone number of the person submitting the grievance
- The Member’s name, address, and telephone number if different from the submitter
- The Member’s Social Security number or the beneficiary’s Social Security number
- A description of the issue(s), including the day, time, and details
- The name of the involved provider(s) or Nova associates
- The provider’s address if the complaint is about a provider
- Any appropriate supporting documents
- If necessary, an Authorization for Disclosure of Medical or Dental Information form
Fax to: 1-805-375-6090
Mail to: Nova Pathfinder Healthcare Limited Grievances 5739 Kanan Road, Suite 335 Agoura, CA 91301