Grievances and Appeals for Loyola Family Care Members | Loyola Medicine

Grievances and Appeals for Loyola Family Care Members

Loyola Family Care wants its members to receive the best possible service. When something goes wrong or you are not treated well, we want to know.

I. GRIEVANCES 

A grievance is a complaint to Loyola Family Care about any matter involving Loyola Family Care other than a denied, reduced or terminated service or medical item. 

Loyola Family Care takes member grievances very seriously. We want to know what is wrong so we can make our services better. Loyola Family Care has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to resolve your problem or concern. Filing a grievance will not affect your healthcare services or your benefits coverage.

These are examples of when you might want to file a grievance with Loyola Family Care:

  • You had trouble getting an appointment with your provider or one of your care coordinators, or talking with your provider or care coordinator, in an appropriate amount of time.
  • Your medical provider or a Loyola Family Care staff member did not respect your rights.
  • Your provider or a Loyola Family Care staff member was rude to you.
  • Your provider or a Loyola Family Care staff member was insensitive to your cultural needs or other special needs you may have.
  • You were unhappy with the quality of care or treatment you received.

Step 1: How to File a Grievance

If you have a grievance about Loyola Family Care or the service you have received:

  1. You can call the Loyola at 888-584-7888 to report it. The TDD/TTY line for those who are deaf or hard of hearing is 708-216-4030.
  2. You can put your grievance in writing and mail or fax it to:

Loyola Family Care, c/o LUHS
2160 S. First Ave.
Maywood, Illinois 60153
Fax: 708-216-0432
Attn: Health Plan Management, Building 108

  1. You can also register your grievance on the Loyola Medicine website, loyolamedicine.org/contact-us

When you file your grievance, give us as much information as you can. For example, include your name and the date and place the incident happened, the names of the people involved and details about what happened.

You can designate another person to help you file a grievance with us. You will need to fill out the authorized representative designation form. You can obtain this form by calling Loyola Family Care at 888-584-7888.

Step 2: Reviewing Your Grievance

We will make a record of your grievance. We will have someone not involved with the matter you are complaining about review your grievance and try to find a solution. Your satisfaction is important to us.

Step 3: Taking Action on Your Grievance

We take action on all grievances within 30 days of receiving them. We will contact you with a response.

Step 4:  If you are not satisfied with the action we take on your grievance, you may write to:

Illinois Department of Healthcare and Family Services Bureau of Managed Care
Attn: ACE Grievances
401 South Clinton Street, 6th Floor
Chicago, IL 60607

The Illinois Department of Healthcare and Family Services (HFS) will review the matter and follow up with you as quickly as possible.

II.   APPEALS  

You may not agree with a decision or an action made by the Illinois Department of Healthcare and Family Services (HFS) or the Illinois Department of Human Services (DHS). An appeal is a way for you to ask for a review of the actions and decisions or HFS or DHS if you do not agree with an action taken or a decision made by the department about your services or a medical item you requested.   

You may appeal within sixty (60) calendar days of the date on the letter from the department informing you of its denial or action. If you want your services to stay the same while you appeal, you must file your appeal no later than ten (10) calendar days from the date on the department’s letter informing you of its denial or action. You can designate another person to help you file an appeal with us. We will need authorization in writing from you for another person to speak on your behalf. When you appeal, you are asking for a hearing to review the department’s action or decision that you disagree with. The person reviewing the department’s action or decision will be a hearing officer.     

You may want to file an appeal if the department:

  • Changes your copayments
  • Does not approve or pay for a service or item that you or your provider asks for 
  • Stops your benefits (coverage)
  • Says that you will start to get fewer benefits

You can also appeal if you think the department made a mistake about any action or decision. You may not get a hearing on your appeal if the department’s action or decision was because of a change in the law.

How to Make an Appeal

When you file your appeal, tell the department what action or decision you disagree with and want them to review. Be sure to include your name, address, phone number, email, and your HFS medical card identification number (the “ID#” next to your name on the medical card).

An appeal is filed either with HFS or DHS, depending on the agency that made the decision you are contesting. Generally, appeal is filed with the agency that made the decision and sent you the letter informing you of its denial or action. 

If you want to file an appeal related to your medical services or items, developmental disability (DD), or elderly waiver (community care program (CCP)) services, send your request in writing via mail, fax or email to:

Illinois Department of Healthcare and Family Services
Attn: Fair Hearings Section
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax: 312-793-2005
Email: HFS.FairHearings@illinois.gov

Or you may call HFS at 855-418-4421. If you use a TTY, call HFS at 877-734-7429. The call is free.

If you want to file an appeal related to your Medicaid application eligibility, food stamps, TANF, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services or any home service program (HSP) services, send your request in writing via mail, fax, or email to:

Illinois Department of Human Services
Attn: Bureau of Hearings
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax: 312-793-3387
Email: DHS.BAHNewAppeal@illinois.gov          

Or you may call DHS at 800-435-0774. If you use a TTY, call DHS at 877-734-7429. The call is free.