The following is a Grievance, Complaint, and Appeal Form that you may complete to register your dissatisfaction with any aspect of your experience with CONCERN. If you need help in filling out this form, please call us at 800-344-4222. Within 5 days of receipt of your complaint, you will receive an acknowledgement letter. A Statement of Resolution will be sent within 5 days of our making a decision concerning your complaint, but not later than thirty days from the receipt of your complaint. You may receive our correspondence by mail or email.
You may also use this form to appeal the resolution of a previously filed complaint. By law, all grievances must be resolved within thirty (30) days of receipt of the complaint. Grievance complaints may be eligible for expedited review in cases involving an imminent and serious threat to the member’s health, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. If you have any questions regarding the grievance process, eligibility for expedited review, or your specific grievance, please call 800-344-4222.
Please be aware we may wish to contact you by phone to discuss details of your complaint to ensure a satisfactory resolution. Be sure to provide, in the section below, a phone number where you can be reached should further discussion be necessary.
You may also use this form to appeal the resolution of a previously filed complaint.
If you have any questions regarding the grievance process or your specific grievance, please contact a Clinical Manager at 800-344-4222. By law, all grievances must be resolved within thirty (30) days of receipt of the complaint.