HNS Policy 

Promoting Safety and Quality

Complaints and Grievances

Policy:

Providers must cooperate fully in the investigation of all complaints, and must promptly respond to any HNS (or payor) requests for information needed to resolve the complaint.

HNS views complaints and grievances as key indicators of the safety, quality, and accessibility of health care services provided by contracted network providers, and complaints and grievances provide an excellent mechanism for identifying safety issues, suboptimal care, or suboptimal compliance to HNS' access and facility site standards.

A complaint or grievance may be related to safety or quality of care, physical aspects of the practice facility, and/or unprofessional behavior by the provider, or the provider's employee(s) or violations of the terms of the HNS Practitioner's Participation Agreement.

Additionally, potential quality, utilization, or risk management issues may be referred to HNS from contracted health care professionals, contracted health care plans, their members, state or federal agencies, or through HNS' ongoing monitoring activities, including but not limited to, the National Practitioner's Data Bank (NPDB) Proactive Disclosure Service.  Complaints and grievances may be submitted to HNS via telephone, facsimile, electronic mail, or the US Postal Service.

HNS' complaints/grievance process provides for reporting complaints and grievances and for timely and appropriate resolution. 

HNS maintains rigorous processes for monitoring, investigating, and resolution of all safety and quality of care complaints lodged against contracted health care providers which are fully described in the HNS Credentialing Plan. 

HNS records and tracks all quality complaints and evaluates both the specific complaint and the contracted health care professional's history, if any, of complaints. HNS also tracks and trends all quality complaints/grievances for opportunities for improvement and for barriers to improvement and take action as necessary to improve patient safety and quality of care. 

Certain substantiated complaints are reported to authoritative bodies, including but not limited to, licensing boards and the National Practitioner's Data Bank (NPDB). 

Network providers must cooperate in the timely resolution of any complaint/grievance, regardless of the source of the complaint. 

Copies of health care and associated financial records for patients whose insurance plan contracts with HNS may be requested at any time by a patient, by HNS or an HNS contracted payor, or state or federal regulatory bodies. 

Requests for copies of health care records should be clearly documented in the health care record and should include the date of the request and the name of the person or entity requesting the records, as well as the date the copies were sent. 

When health care records are requested, providers must promptly respond to such requests.

Requests from Payors or Regulatory Authorities

If requested, network providers are required to submit all information requested by contracted payors, including but not limited to, copies of health care records. If a "Due Date" is provided in the request, information must be received by the stated due date.  If a "Due Date" is not provided, information must be submitted to the payor within ten days of receipt of request.

 Requests from HNS

Network providers are required to submit all information requested by HNS to resolve complaints, including but not limited to, copies of health care records, and providers must promptly comply with such requests.  All requests from HNS for information needed to resolve a complaint will include a "Due Date" and information must be submitted to HNS by the "Due Date" stated.

Requests from Patients

Network providers are required to provide copies of health care records if requested by the patient and providers must promptly comply with such requests.  Network providers must provide patient with copies of the health care record within ten days of receipt of request from patient.

Providers should never release original records; only copies of the records should be released.  When copies of records are requested by patients, the patient should sign and date an authorization to release records and a copy of the authorization should be maintained in the patient's health care record.