Complaint, Appeal, and Hearing

What is the PHC grievance process?

​It is the way we work with and resolve member complaints about the services they received as PHC members.

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 (insert health plan's telephone 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 Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

 

When would I file a complaint?

Examples of when to file a complaint are:

  • You are having a problem getting services you feel you need (For example, if you are having problems getting medication or medical equipment, problems getting an appointment with your doctor or problems getting treatment at the hospital);
  • You disagree with a decision PHC made about you/your child's eligibility;
  • You are not happy with the services you got from a PHC provider;
  • You disagree with PHC when we deny a service you feel you need; and
  • You feel that a health care provider or PHC has not respected your privacy.

You must file your complaint within 180 days of the event that caused you to be dissatisfied.

How do I file a complaint?

You can file a complaint one of the following ways:

  • Over the phone by calling a Member Services Representative at:
    • 707-863-4120 or 800-863-4155
    • For the hearing or speech impaired call 800-735-2929, or call 711.
  • By writing down your complaint and sending it to the Grievance Unit at the following address:

Partnership HealthPlan of California
4665 Business Center Drive
Fairfield, CA 94534

  • Or by logging onto our Internet Website http:/www.Partnershiphp.org and completing a complaint form and emailing it to the Grievance Unit.
  • By coming to our office in person, M-F, 8am-5pm. We are located at:

4665 Business Center Drive
Fairfield, CA 94534

What if I speak little or no English?

​PHC has bilingual staff that speaks Spanish, Russian and Tagalog that can help you file your complaint. If you speak a language other than English, Spanish, Russian or Tagalog, we will arrange for interpreter services for you through a telephone language line.

Do I have to use the PHC grievance process to resolve my problem?

Yes. You must use the PHC grievance process to resolve your complaint, except in the case of an urgent grievance, as described in Section 6 of this document.

If you are unhappy with PHC's decision or your complaint is not resolved after 30 calendar days, then you can contact the California Department of Managed Health Care (DMHC) at 1-888-HMO-2219 or the TDD line at 1-877-688-9891 (for the hearing and speech impaired) and ask them to review your complaint.

As a PHC member, you have the right to file a complaint with the Department of Health and Human Services at any time if you feel that your privacy has not been respected. You can file your complaint by contacting:

Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201

What if my complaint involves an immediate or serious threat to my health and well being?

If the complaint involves an imminent or serious threat to your health, including but not limited to, severe pain, potential loss of life, limb, or major bodily function, an earlier review is warranted. This kind of complaint is called an expedited complaint.

The Grievance Unit will acknowledge the complaint in writing within twenty-four (24) hours of receipt and immediately notify you of your right to notify the DMHC of the complaint without first participating in the PHC grievance process.

PHC will notify you of its decision, both orally and in writing, as expeditiously as the medical condition requires, but no later than (3) calendar days. PHC will also provide the DMHC with a written statement on the disposition or pending status of the complaint no later than three (3) days from receipt of the complaint.

Can I have someone help me file my complaint?

​Yes, you can have a family member or a friend help you. You also have the right to obtain representation by an advocate or legal counsel to assist you in filing and/or resolving your complaint. You may obtain information about legal counsel from several sources, including Legal Services of Northern California (LSNC).

What happens after I file my complaint?

​The Grievance Unit will send you a letter within five (5) calendar days after you file your complaint. This letter tells you that we received your complaint. It explains your rights in the grievance process.

How does my complaint get settled?

​Depending on the type of complaint you have, our staff may be able to resolve it right away to your satisfaction. If this is not possible, your complaint will go to the appropriate PHC staff. They will review your complaint in detail and look at the information that was sent to the Grievance Unit. If more information is needed, they ask for it. For example, if the Medical Director wants more information, s/he may ask for it from the doctors involved. This may include requesting copies of your medical records. After all the information is collected and a decision is made, the Grievance Unit will send you a resolution letter.

How long do I have to wait until I get the resolution letter?

The Grievance Unit will send you the resolution letter within 30 calendar days from the day your complaint was received.

If you accept the proposed resolution, the complaint is closed and filed. If you do not accept the proposed resolution, you have the right to file a complaint with DMHC or to request an Independent Medical Review (IMR) by the DMHC.

What can I do if I don't agree with the resolution?

You have the right to:

  • File a complaint with the Department of Managed Health Care (DMHC). Their telephone number is 1-888- HMO-2219. The TTD line is 877-688-9891 for the hearing and speech impaired. You may also file a complaint with the DMHC if it takes PHC longer than 30 days to resolve your complaint; or
  • Request an Independent Medical Review (IMR) if your complaint involves a denial or partial denial of a health care service if it was decided that the service is not medically necessary.
    DMHC also has an Internet Website http://www.hmohelp.ca.gov that has complaint forms and applications for an IMR.

If you feel PHC has violated your privacy, you have the right to file a complaint with the Department of Health and Human Services at any time by contacting:

Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201

Department of Managed Health Care Statement

​The California Department of Managed 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 707-863-4120 or toll-free 1-800-863-4155 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 an IMR, the IMR process will provide an impartial review of medical decisions made by the health plan related to 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.