Part 3: For Your Information
If you wish to file a complaint or appeal a decision, the process used to resolve your complaint or appeal is called the Grievance Process. Complaints can be filed at any time. Appeals must be filed within 60 days from the date of the Notice of Action, service, benefit or claim. A Notice of Action is a formal letter sent to you by California Health and Wellness telling you that a medical service has been denied, deferred or modified.
If your appeal is urgent, you may ask for an “expedited review.” Your appeal can be reviewed within 72 hours from the date it was received, if it involves an immediate or serious threat to your health, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function.
Within five (5) calendar days of receipt of your request for a grievance, California Health & Wellness grievance unit will send you an acknowledgement letter saying we received your grievance. The letter will also give you the name, address and phone number of the California Health & Wellness grievance staff that will be handling your grievance and the date your grievance was received. Along with that letter, the grievance staff will also send you information that describes the grievance process, outlines your rights in the grievance process, provides information about the State Hearing process and also provides address and phone numbers of local Northern California Legal Aid offices.
The grievance staff will try to get more information which may help us decide on a better resolution of your grievance. If necessary, the California Health & Wellness grievance staff may contact you if she/he has any questions about your grievance or if more information is needed.
You can contact the California Health & Wellness grievance staff to discuss your grievance. Within thirty (30) calendar days from the date of receipt of the grievance, the California Health & Wellness grievance staff will mail a written letter that outlines California Health & Wellness' resolution to your grievance.
You may, at any time, contact the government agency that that regulates health care services plans regarding your grievance or appeal that California Health & Wellness has not resolved or has not resolved to your satisfaction.
California Department of Managed Health Care (DMHC)
The California Department of Managed Health Care (DMHC) 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) (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) 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-HMO-2219 and a TDD line 1-877-688-9891 for the hearing and speech impaired. The department’s internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
State Fair Hearing
You may ask for a State Hearing within 120 calendar days from Notice of Resolution (NAR). You may either present your case yourself or ask someone to present your case, such as legal counsel, relative, friend or any other person. You can request an appeal and a State Hearing at the same time. For more about State Hearing requests, please call 1-800-952-5253. For hearing impaired TDD, please call 1-800-952-8349. To request a Sate Hearing in writing, please send your letter to the following address: California Department of Social Services, State Fair Hearing Division, P.O. Box 944243, MS 19-37, Sacramento, CA 94244-2430.
California Department of Health Care Services (DHCS) Office of the Ombudsman
You may also call the Ombudsman Office of the California Department of Health Care Services (DHCS) for help. The Ombudsman Office helps Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. To find out more, call tol-free 1-888-452-8609.