TEMPLATE G7 - Failure to Provide Service(s)/Item(s) in a Timely Manner Acknowledgment Letter

Sep 16, 2026

Acknowledgment letter template (Template G7) for participants who file a complaint about not receiving required service(s) or item(s) within the expected timeframe. The letter informs the participant of complaint receipt, outlines the complaint review by independent CHC-MCO staff, explains representation and attendance options, and provides expected mailing timelines for the decision. It also includes how to request information, request an early decision when health would be harmed by delay, and obtain help and free legal assistance.

LanguageEnglish

CategoryLetters

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

TEMPLATE G(7) FAILURE TO PROVIDE SERVICE(S)/ITEM(S) IN A TIMELY MANNER ACKNOWLEDGMENT LETTER

Complaint Process

Complaint Review

Information About Your Complaint

Ask for an Early Decision

Help with Your Complaint

TEMPLATE G(7) FAILURE TO PROVIDE SERVICE(S)/ITEM(S) IN A TIMELY MANNER ACKNOWLEDGMENT LETTER [Date Letter Mailed] Participant Name Address City, State Zip Participant ID: ********* Subject: Your Complaint About [Complaint Issue] Dear [Participant Name] : [CHC-MCO Name] received your Complaint on [date of Complaint] that you did not get your [type of services/items] in the time you should have. If your Complaint is described correctly, please sign and send back the enclosed“Complaint Issue” form. If your Complaint is not described correctly, please call [CHCMCO Name] at [CHC-MCO Phone \# &Toll Free TTY/PA RELAY] The Complaint Process Complaint Review A committee of one or more [CHC-MCO Name] staff will meet to make a decision about your Complaint. This is called the “Complaint review.” The [CHC-MCO Name] staff on the committee were not involved in and do not work for someone who was involved in the issue you filed your Complaint about. At any time during the Complaint review process, you can have someone you know represent you or act for you. This person is “your representative.” If you decide to have someone represent you or act for you, tell [CHC-MCO Name], in writing, the name of that person and how we can reach him or her. [CHC-MCO Name] will tell you the location, date, and time of the Complaint review at least 10 days before the day of the Complaint review. You and your representative may appear at the Complaint review in person or by phone. [OR if video conference is available: You and your representative may appear at the Complaint review in person, by phone, or by videoconference.] You may also bring a family member, friend, lawyer, or other person to help you during the Complaint review. If you decide that you do not want to attend, that will not affect the decision of the committee. [CHC-MCO Name] will mail you a letter within [date that is no more than 30 days from receipt of the Complaint] days from the date [CHC-MCO Name] got your Complaint to tell you the decision on your Complaint. Information About Your Complaint You or your representative may ask [CHC-MCO Name] to see any information about the issue you filed your Complaint about , at no cost to you. You may also send information that you have about your Complaint to [CHC-MCO Name] . Use the following to ask for information about your Complaint or to send information to [CHC-MCO Name]: • Phone number: [CHC-MCO Phone \# &Toll Free TTY/PA RELAY]; • Fax number: [CHC-MCO FAX \#]; or • Mailing address: [ADDRESS FOR REQUESTING/SENDING INFORMATION] Ask for an Early Decision If your doctor or dentist believes that waiting [30, unless the CHC-MCO will be using a shorter time frame to provide notice of 1st Level Complaint decisions] days to get a decision could harm your health, you may ask that your Complaint be decided more quickly. For your Complaint to be decided more quickly: You must ask for an early decision by calling [CHC-MCO Name] at [Phone\# & Toll-free TTY/PA RELAY \#] or faxing a letter or the “Complaint Request Form”to [CHC-MCO FAX \#] . Your doctor or dentist should fax a signed letter to [CHC-MCO FAX \#] within 72 hours of your request for an early decision that explains why [CHC-MCO Name] taking [30, unless the CHC-MCO will be using a shorter time frame] days to tell you the decision about your Complaint could harm your health. [CHC-MCO Name] will tell you the decision about your Complaint within 48 hours from when [CHC-MCO Name] gets your doctor’s or dentist’s letter, or within 72 hours from when [CHC-MCO Name] gets your request for an early decision, whichever is sooner, unless you ask us to take more time to decide your Complaint. You can ask us to take up to 14 more days to decide your Complaint. Help with Your Complaint If you need help with your Complaint , you can call [CHC-MCO Name] at [Phone \#/Tollfree TTY\#] . To ask for free legal help with your Complaint , you can call: • Pen

FAQs

What should a participant do after receiving this acknowledgment letter?

If the complaint issue is described correctly, the participant should sign and return the enclosed “Complaint Issue” form. If it is not described correctly, the participant should contact the CHC-MCO by phone.

Who conducts the complaint review and can the participant bring representation?

A committee of one or more CHC-MCO staff will review the complaint and decide. Staff on the committee are not involved in the issue, and the participant may have a representative and may appear in person or by phone (or videoconference if available).

How can the participant request an early decision, and how quickly will the decision be made?

If a doctor or dentist believes waiting would harm health, the participant can request an early decision by calling or faxing a request. The CHC-MCO will provide the decision within 48 hours of receiving the doctor/dentist letter or within 72 hours of the early decision request, whichever is sooner, unless more time is requested.

Sep 16, 2026

Upload by Maya Linwood