The Health Care Center is committed to the health and well-being of our members. To that end, we offer caring, service-oriented people who work daily with your best interests in mind-including providing timely solutions to any concerns you may have. If you should have a concern about your medical care, we encourage you to first discuss it with your primary care physician. In the event you have a concern that cannot be resolved through either our Member Services Department or your primary care physician, you will need to contact your health plan or an agency that monitors or regulates health plans to file a grievance or appeal. The following is an overview of the options available to you.
You, or a representative appointed by you on your behalf, may file a written quality complaint with your health plan. The health plan refers to this process as a "grievance". The grievance process allows the member to file a complaint with the health plan about issues other than a denied service. This process is separate from the appeal process described in the "Member's Rights to Appeal a Denied Service & Appeal Process" section below. Please refer to your health plan member materials for more detailed instructions on how to file a complaint/grievance.
If you are concerned about the quality of care you have received, you, or a representative appointed by you to act on your behalf, may also file a complaint with the local Peer Review Organization, California Medical Review, Inc. (CMRI) at 1-800-841-1602. Peer Review Organizations are groups of doctors and health professionals that monitor the quality of care provided. The Peer Review Organization review process is designed to help stop any improper practices.
If you believe that the resulting determination is not correct, you, or a representative appointed by you to act on your behalf, has the right to appeal through your health plan. Your health plan requests that you submit your appeal within 60 days of your medical group's/IPA's final determination. Your request may be verbal or in writing. There are two methods of appeals: Standard or Expedited.
A standard appeal will be processed within 30 working days. Please submit a copy of your denial notice and a brief explanation to the address indicated by your health plan coverage card, or call your health plan's Customer Service department who will document and research your request.
Your health plan makes every effort to process your appeal as quickly as possible. In some cases, you have the right to an expedited appeal when a delay in the decision might pose an imminent and serious threat to your health including, but not limited to, possible life, limb, or major bodily function. If you request an expedited appeal, your health plan's health services department will evaluate your request and medical condition to determine if your appeal qualifies as expedited, which will be processed within 72-hours. If not, your appeal will be processed within the 30 standard days.
You or your practitioner may file a verbal or written request for an expedited appeal. You should specifically state that you are requesting an expedited appeal because you believe your health might be seriously jeopardized by waiting for the standard appeal process.
Your health plan will make a decision on your expedited appeal and will notify you of the decision within 72-hours after the review commences. You will receive written confirmation of the decision within two working days. If your health plan's decision is not in your favor, and you disagree with the decision, you may request an expedited review by the Appeals and Grievance Committee. A hearing before the Appeals and Grievance Committee will be scheduled within 10 working days. You must contact your Health Plan to arrange the hearing to review your case.
In addition to the complaint processes described above, you may also contact the California Department of Managed Health Care (DMHC). The DMHC is responsible for regulating health care service plans. The DMHC's Health Plan Division has a toll free telephone number-1-800-400-0815-to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service's toll-free numbers-800-735-2929 (TTY) or 1-888-877-5378 (TTY)-to contact the department. Complaint forms and instructions can be accessed online at DHMC .
If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 60 days, you may call the DMHC's Health Plan Division for assistance. It's important to note, however, that if you have a grievance against your health plan, you should first telephone your health plan and use their grievance process before contacting the DMHC.