If you as a provider have any issue, complaint, or grievance with EBCI Tribal Option, we will attempt to resolve it as quickly as possible. The process begins with you making a formal appeal in the following ways.

Here is the provider grievance process:

  • EBCI Tribal Option has developed a Provider Grievance Policy that establishes how PCPs may express dissatisfaction about any matter related to the agreement between the PCP and EBCI Tribal Option.
  • Provider Grievances may be related to, but are not limited to, issues regarding quality of care, professional conduct, and program fraud.
  • PCPs may file a Provider Grievance about the contractor’s employees, other PCPs, their staff, EBCI Tribal Option’s subcontractors, other members, or other personnel.
  • EBCI Tribal Option shall allow the PCP to file a Provider Grievance either orally or in writing at any time and shall acknowledge receiving the Grievance.
  • EBCI Tribal Option shall make a decision regarding the Provider Grievance and provide notice to the PCP of its decision within fifteen (15) CIHA business days of receipt of the Provider Grievance.
  • EBCI Tribal Option may extend the time frame for processing a Grievance by up to fourteen (14) calendar days if the contractor shows there is a need for additional information and that the delay is in the PCP’s best interest.
  • If a PCP is dissatisfied with the disposition of a Grievance, the PCP may bring the unresolved Grievance to the NCDHHS.
  • You can learn more about the Tribal Option Member and Provider Grievance Policy here.

Provider grievances: record-keeping and reporting.

  • Consistent with 42 C.F.R. § 438.66(c)(3), EBCI Tribal Option shall maintain a Provider Grievance Log.
  • EBCI Tribal Option shall maintain records of all PCP grievances and shall review the information as part of its ongoing monitoring procedures.

Filing grievances directly with NCDHHS.

  • PCPs shall also have the option to file a grievance directly with NCDHHS.
  • If NCDHHS is contacted by a provider (PCP or otherwise) or other individuals/entities with a grievance regarding concerns about EBCI Tribal Option, EBCI Tribal Option shall address all issues as soon as possible after NCDHHS has informed EBCI Tribal Option of the concern. 
  • EBCI Tribal Option shall keep NCDHHS informed about progress on resolving concerns in real time and shall advise NCDHHS of the final resolution. 
  • You may also request a hearing. Click here for more information.

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