Grievances & Appeals

Soundpath Health offers grievances, organization determinations, coverage determinations (including exceptions) and appeals processes.

Grievances

A grievance is any complaint that is not related to a denial of service. If you experience problems or issues that are not related to your benefit coverage, you have the right to file a grievance:

  • When you disagree with our decision to transfer an expedited appeal to the standard appeal process
  • Problems with our Member Services
  • Problems with getting appointments in a timely manner
  • Disrespectful or rude behavior by pharmacists, providers or other medical staff

Organization Determinations

Organization determinations are coverage decisions for medical care/items received and may also include exception requests for a prescription drug. An exception request is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs, known as a formulary exception, or if you believe you should get a non-preferred drug at a lower out-of-pocket cost known as a tiering exception.

Please note: you do have the right to appeal any coverage denial. Soundpath Health will tell you how to appeal in the denial notice we send to you that will explain our denial decision.

Appeals

If you do not agree with a decision we have made to deny payment of health care claims or if we are stopping payment for services you are already receiving, you may file an appeal within 60 calendar days from the notice of denial date.

There are two kinds of appeals you can file: standard and expedited (rush). A standard appeal request for medical treatment that has been denied must be in writing using the Appeal Request Form and sent to:

Soundpath Health
Attn: Grievance and Appeals
32129 Weyerhaeuser S Suite 201
Federal Way, WA 98001-9346

A standard appeal request for Part D prescription drugs that have been denied or you believe should be covered, can be submitted verbally by calling 1-866-789-7747 (TTY/TDD 1-866-264-4141) Monday-Friday between 8am-5pm or in writing using the Appeal Request Form to the address listed above.

An expedited appeal can be submitted in writing using the Appeal Request Form to the address above, or verbally by calling 1-866-789-7747 (TTY/TDD 1-866-264-4141), Monday-Friday between 8am-5pm. You should file an expedited appeal if you health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision. You can also fax your request to 253-779-8829 or deliver it in person to the address listed above.

If you have questions on how to file a grievance or an appeal you can also call Member Services at 1-866-789-7747 (TTY/TDD 1-866-264-4141), Monday-Friday between 8am-5pm. 

Anything submitted in writing should be sent to:

Soundpath Health
Attn: Grievance and Appeals
32129 Weyerhaeuser S Suite 201
Federal Way, WA 98001-9346

Please refer to your Evidence of Coverage for more detailed information regarding grievances and appeals. Review Chapter 9, Section 4 in your Evidence of Coverage for more information on coverage determinations and appeals. Review Chapter 9, Section 10 in your Evidence of Coverage for more information on the grievance process. Click here to access Soundpath Health's Evidence of Coverage documents.

Page Last Updated: October 6, 2011