Filing an Appeal
You will know that California Health & Wellness is taking an action because we will send you a letter. The letter is called a Notice of Action (Action). Actions occur when California Health & Wellness:
- Delays or denies the care requested.
- Decreases the amount of care.
- Ends care that has previously been approved.
- Denies payment for care and you may have to pay for it.
If you do not agree with the Action, you may request an appeal. An appeal is a request to review a Notice of Action. This review makes us look again at the Notice of Action. You can request this review online at www.CAHealthWellness.com, by phone, or in writing.
Who may file an Appeal?
- You, the Member (or the parent or guardian of a minor Member).
- A person named by you.
- A doctor acting for you.
You must give written permission if someone else files an appeal for you. California Health & Wellness will include a form in the Notice of Action letter. You can also obtain this form on our website at www.CAHealthWellness.com. Contact Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) if you need help. We can assist you in filing an appeal.
When Does an Appeal Have to be Filed?
The Notice of Action will tell you about this process. You may file an appeal within 60 calendar days from the date of the Notice of Action.
You may ask to keep getting care related to your review while we decide. You may have to pay for this care, if the decision is not in your favor.
Except in urgent cases, California Health & Wellness will give you a written decision within 30 calendar days from the date of your request. If more than 30 calendar days is needed to make a decision, we will send a letter to you. California Health & Wellness will ask for extra time if more information is needed. The extra time may be better for your case. California Health & Wellness will ask for the extra 14 calendar days in writing. The letter will say why we need more time.
You or your doctor may want us to make a fast decision. You can ask for an Expedited Review if you or your doctor feel that your health is at risk. If you feel this is needed, call our Grievance and Appeal Coordinator at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number). We will decide within 72 hours of receipt of the appeal request. However, the review period may be up to 14 days. California Health & Wellness will make reasonable efforts to contact you by phone if your appeal is denied. You will also receive a letter telling the reason for the decision and what to do if you don’t like the decision.
Medi-Cal Fair Hearing for Appeals
What if I’m still not happy?
If you are dissatisfied with California Health & Wellness' decision, you may request a State Fair Hearing after you have exhausted your appeal rights with California Health & Wellness.
You or your doctor may request a State Fair Hearing within 120 calendar days of receiving the notice of adverse resolution. If you are currently receiving a medical service that is going to be reduced or stopped, you may continue to receive the same medical service until the hearing if you request the hearing within 10 calendar days from the date the denial letter was postmarked.
To request a State Fair Hearing from Medi-Cal, please call or write to:
State Department of Social Services State Hearing Division
P.O. Box 944243, Mail Station 19-37
Sacramento, CA 94244-2430
California Department of Managed Health Care (DMHC)
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-877-658-0305) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. 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 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.