Managed Care Grievances, Appeals, and Potential Litigation Checklist

Summary

This checklist addresses grievances, appeals, and potential litigation resulting from managed care decisions. It outlines the issues involved in requesting a review of managed healthcare determinations and the basis upon which they are made. The required procedures differ by contract but do have similarities. Differences may exist due to the structure of the managed care entity itself. Because some models of managed care are themselves risk-bearing, insurance regulators are frequently involved in regulating managed care entities and are involved in aspects of their operation, including appeal procedures.