Complaints, Grievances and Appeals System

A complaint is an expression of dissatisfaction about any matter other than an Adverse Benefit Determination that is resolved at the point of contact.  If you are not agree with the care that you are getting, call First Medical at 1-844-347-7800. Tell them that you need to make a complaint. You can also visit First Medical Service Offices. Your doctor, a family member, or your representative can make a complaint for you if you authorize them to do so. You can make a complaint at any time.  First Medical has seventy-two (72) hours to fix your complaint. First Medical has up to ninety (90) calendar days to fix it, but they have to decide faster if it’s important to your health. First Medical must tell you how the complaint was fixed.  If they can’t fix your complaint quickly, it will become a “grievance”.

A grievance is a formal claim made by the Enrollee in writing, by telephone or by visiting First Medical or the Health Advocate Office, requesting a solution be granted when a service has been denied or allowed on a limited basis. You can call, write or visit First Medical Service Centers to file a grievance. Your doctor, a relative or a person authorized by you, can file the grievance on your behalf. You may file a grievance at any time from the date of the occurrence.

If First Medical make a decision about your care that you don’t agree with, you or your authorized representative or provider (acting on your behalf and with you consent) can file an appeal. When you appeal, you’re asking First Medical to reconsider the decision. You must file the appeal request within sixty (60) calendar days from the date included on the notice of our initial determination. You may ask us to review our initial determination, even if only part of our decision is not what you requested.

After we receive your appeal, we have thirty (30) calendar days to decide, but will decide sooner if your health condition requires. First Medical must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you or your representative. If your life or rehab process requires that First Medical review your case promptly, you can ask for an expedited or fast appeal. You, your doctor, or your representative can ask for a fast appeal by calling First Medical or visiting any of our Service Offices. If First Medical agrees to give you a fast appeal, they will decide your case within seventy-two (72) hours. If First Medical does not agree to give you a fast appeal, they will call you within two (2) business days to let you know they will decide your case within thirty (30) calendar days.

To ensure that the grievance procedure is accessible to all members and is provide in a culturally competent manner, including those with limited English or Spanish proficiency or reading skills, and those with diverse cultural and ethnic backgrounds, First Medical will provide the following services, free of charges, when necessary:

  • TTY Line (the number for the hearing impaired, TTY/TDD users should call 1-844-347-7805) Monday through Sunday from 8:00 a.m. to 7:00 p.m.
  • Sign Language, Foreign Language Interpreter and Written Translation Services
  • Audio Tapes
  • Braille