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OPS-SOP-029 — Member Issue Escalation & Resolution

Document IDOPS-SOP-029	Version1.0	Effective Date[TBD — upon adoption]	Next ReviewAnnually	OwnerOperations
Prepared ByOperations

1. Purpose

This SOP defines the process for receiving, triaging, routing, escalating, and resolving member issues across all participating employer groups in the Unity Care Member Plan Master Trust. It establishes SLAs, escalation paths, logging requirements, and a monthly trend review process to identify systemic issues requiring vendor or plan design action.

2. Scope

Applies to all member complaints, billing disputes, claim denials, network access issues, and prescription coverage issues received from any source. Covers both employer HR-routed issues and direct member contacts. Does not govern formal ERISA external review (see escalation path in Section 7), but does trigger and track that process.

3. Issue Categories

Category	Description	Primary Routing
Claim Denial	Claim submitted and denied (fully or partially) by Allied Benefit Systems. Includes pre-authorization denials, medical necessity denials, and out-of-network denials.	Allied Benefit Systems — Appeals Process
Billing Error / Dispute	Member received an unexpected bill from a provider; incorrect cost-sharing applied; billing code error; balance billing concern.	Allied Benefit Systems (medical) or ProAct (pharmacy)
Network Issue	Member unable to locate in-network provider; provider claims to be in-network but Allied shows otherwise; adequacy concern for specialty or geographic access.	Allied Benefit Systems — Network Adequacy Review
Prescription Coverage Issue	Drug not covered under formulary; incorrect tier applied; prior authorization required for medication; specialty drug access issue.	ProAct (PBM) — Formulary Review / PA Process
Enrollment / Eligibility Error	Member showing as inactive when they should be active; dependent not enrolled; wrong plan option on file.	Allied (enrollment correction) / Operations (data fix)
General Complaint	Member dissatisfaction with service, communication, or plan terms not fitting another specific category.	Operations — assess and route accordingly

4. Intake Channels

Member issues are received through two primary channels:

Employer HR → Operations: The employer's HR contact receives the member's issue and forwards to Operations via email or the designated issue intake method. This is the preferred channel for all plan-related member issues.
Member Direct to Operations: Members may contact Operations directly. Operations acknowledges the issue and coordinates with employer HR as needed before routing.

Note on Direct Member Contact: Operations does not provide legal advice, make coverage determinations, or override plan design in member communications. Operations facilitates routing and resolution through the appropriate vendor. Members with ERISA claim denials must be directed to the formal appeals process.

5. SLA — Service Level Agreement

SLA Target	Timeframe	Owner
Acknowledge receipt of issue to employer HR or member	1 business day of intake	Operations
Triage and route to appropriate vendor or process	1 business day of intake	Operations
Resolve or escalate to next tier	5 business days of intake	Operations / Vendor
Provide status update to employer HR or member if unresolved at 5 days	Day 5 if unresolved	Operations
ERISA appeals acknowledgment (formal denial appeal)	Within 5 business days per ERISA / plan documents	Allied Benefit Systems (claims)

Urgent Issues: Issues involving denial of urgent or emergency care, life-threatening conditions, or expedited review requests are escalated immediately to Allied and Legal Counsel regardless of standard SLA timelines. Operations flags these on intake and monitors same-business-day.

6. Triage & Routing Process

Step 1 — Intake & Log

Operations receives the issue and logs it in the Member Issue Log (see Section 8) within 1 business day. Log entry includes: date received, member name (or member ID), employer group, issue category, description, intake channel, and Operations contact handling the issue.

Step 2 — Acknowledge

Operations sends an acknowledgment to the employer HR contact (or directly to the member if direct intake) within 1 business day confirming receipt and providing an estimated timeline for resolution or next steps.

Step 3 — Categorize & Route

Operations categorizes the issue using the table in Section 3 and routes to the appropriate vendor:

Claim denial → Operations contacts Allied (Kim James or Allied member services) to initiate the formal appeals process. Operations provides the member with Allied's appeals procedure and deadlines from the SPD.
Billing error → Operations contacts Allied (medical bill) or ProAct (pharmacy bill) with member information and a description of the error. Requests correction and provides timeline to member.
Network issue → Operations contacts Allied for network adequacy review. If an in-network provider is misidentified, requests correction. If geographic access is insufficient, escalates to Leadership for plan design discussion.
Prescription issue → Operations contacts ProAct (via PBM contact Dolores Hynes or ProAct member services) for formulary tier review, prior authorization status, or formulary exception request. Provides member with ProAct exception process if needed.
Enrollment / eligibility error → Operations corrects enrollment data with Allied and confirms resolution. If employer-side payroll issue caused the error, notifies employer HR for correction.

Step 4 — Monitor & Follow-Up

Operations monitors open issues daily against the SLA. If vendor response is not received within 3 business days, Operations sends a follow-up and escalates to a supervisor contact at the vendor if needed. Status is logged in the Member Issue Log.

Step 5 — Communicate Resolution

Upon resolution, Operations communicates the outcome to employer HR (and/or the member directly if appropriate) in writing. Resolution details and date are logged in the Member Issue Log.

7. Escalation Path

Tier	Condition	Action
Tier 1 — Operations	All issues on intake	Acknowledge, triage, route to vendor. Resolve within 5 business days.
Tier 2 — Legal Counsel	ERISA claim denial requiring external independent review; potential fiduciary liability; member threatening legal action; issues involving HIPAA breach	Operations escalates to Legal Counsel (Dickinson Wright PLLC) in writing. Legal Counsel advises on ERISA external review process, required response timelines, and fiduciary obligations.
Tier 3 — Leadership	Systemic issue affecting multiple members or employers; vendor performance failure; plan design deficiency identified through trend review; media or regulatory inquiry	Operations prepares a written briefing for Leadership. Leadership determines whether plan design change, vendor contract action, or regulatory response is warranted.

ERISA External Review: When a claim denial has been upheld on internal appeal, the member may have the right to an independent external review under ERISA and applicable state law. Operations ensures the member receives information about external review rights in accordance with the SPD and Allied's denial notices. Legal Counsel coordinates external review procedures.

8. Member Issue Log

Operations maintains a perpetual Member Issue Log. Each entry must include:

Field	Description
Issue ID	Unique sequential identifier (e.g., MIL-2026-001)
Date Received	Date Operations received the issue
Employer Group	Participating employer name
Member ID / Name	Member identifier (use ID where possible to limit PHI exposure in the log)
Issue Category	Claim denial / billing error / network / prescription / enrollment / general
Description	Brief summary of the issue (1–3 sentences)
Vendor Routed To	Allied / ProAct / HealthEquity / Varipro / Other
SLA Target Date	Date by which resolution or escalation is required
Status	Open / In Progress / Escalated / Resolved
Resolution Date	Date issue was resolved
Resolution Summary	How the issue was resolved; any corrective action taken
Escalation Level Reached	Tier 1 / Tier 2 (Legal) / Tier 3 (Leadership)

9. Monthly Trend Review

On or before the 10th of each month, Operations reviews the prior month's Member Issue Log to identify patterns and systemic issues:

Aggregate issues by category, employer group, and vendor to identify concentrations.
Identify any issue types that exceeded SLA targets — root cause and corrective action documented.
Identify recurring issues with a specific vendor (Allied, ProAct, HealthEquity, Varipro) that may indicate a vendor performance problem — escalate to vendor account manager with written notice.
Identify issues suggesting a plan design gap (formulary gaps, network access, ambiguous benefit language) — document and flag for next plan year design review or immediate SMM if correction is urgent.
Prepare a one-page monthly Member Issue Summary for Leadership review. Include: total issues by category, SLA performance, open items, escalations, and any recommended actions.

Systemic Issue Threshold: If three or more similar issues are identified within a 60-day period (same category, same root cause, or same vendor), Operations treats this as a systemic issue and escalates immediately to Leadership per the Tier 3 path, regardless of whether individual issues have been resolved.

10. Related Documents

OPS-SOP-022 — SPD / SBC Production, Review & Distribution (for appeals procedure language)
OPS-SOP-021 — Annual Compliance Deadline Calendar
ERISA §503 — Claims and Appeals procedure requirements
29 CFR §2560.503-1 — DOL claims procedure regulation
ERISA §712 / MHPAEA — Mental health parity in claims decisions
No Surprises Act (NSA) — Independent Dispute Resolution (IDR) process for balance billing