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Medi-Cal - How to File a Member Complaint, Appeal and Hearing Information

Section 1 - How to File a Complaint or Appeal
Section 2 - Grievance Process
Section 3 - Expidited Review of Your Grievance Process
Section 4 - Your Rights in the Grievance Process
Section 5 - State Hearing Information
Section 6 - Legal Services of Northern California
Request for an Appeal or Complaint Form

SECTION 1

How to File a Complaint or Appeal

An Appeal is a member's request to PHC for reconsideration of an initial decision resulting in the denial of a service, benefit or claim. A Complaint is a member's expression of dissatisfaction regarding PHC and/or a provider that includes, but are not limited to, quality of care concerns.

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 and appeals must be filed within 180 calendar days following any incident or action that you are not satisfied with.

If you have a problem with your Medi-Cal, AFDC, or SSI eligibility, do not request a grievance from PHC. We do not process such grievances. Your Medi-Cal benefits are determined by the State of California and the Department of Health Services.

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SECTION 2

Grievance Process

If you want to file a complaint or if you disagree with a decision made by PHC or a provider, you may file a grievance.

Filing a Grievance

Members or a member's authorized representative may file a grievance by using one of the four methods listed below:

By Telephone: You may file a grievance or ask questions about the grievance process by calling the PHC Member Services Department at 707-863-4120 or 1-800-863-4155. Bilingual staff is available and PHC uses the AT&T telephone interpreter service for members who speak other languages.

In Writing: You may file a grievance in writing to PHC. Written grievances should be sent to:
In Person: You may file your grievance in person by visiting PHC's office at:
Contracted Provider: You may file your grievance at the office of any provider that is contracted with PHC. Forms titled "Request for a Complaint or Appeal" may be used to file your Grievance. These forms are located at all provider offices that are contracted with PHC.

Processing your Grievance

Within five (5) calendar days of receipt of your request for a grievance, the PHC Grievance Coordinator 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 PHC Grievance Coordinator that will be handling your grievance and the date your grievance was received. Along with that letter, the Grievance Coordinator will also send you a form (this form) that describes the grievance process, outlines your rights in the grievance process, provides information about the State Fair Hearing process and also provides addresses and phone numbers of local Northern California Legal Aid offices.

The Grievance Coordinator will work hard to get more information which may help us decide on a better resolution of your grievance. If necessary, the PHC Grievance Coordinator may contact you if she/he has any questions about your grievance or if more information is needed.

You can contact the PHC Grievance Coordinator to discuss your grievance.

Within thirty (30) calendar days from the date of receipt of the grievance, the PHC Grievance Coordinator will mail a written letter that outlines PHCs resolution to your grievance.

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SECTION 3

Expedited Review of Your Grievance

If your grievance is urgent, you may ask for an "expedited review". Your grievance can be reviewed within three (3) calendar days from the date it was received, if it involves an imminent and serious threat to your health, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function.

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SECTION 4

Your Rights in the Grievance Process

As a member of the Partnership HealthPlan of California (PHC), you have the following rights in filing a grievance with PHC:

You will receive a written acknowledgement to your grievance request within five (5) calendar days from the date your grievance was received. The acknowledgement letter will let you know the day that PHC received your grievance request and the name, address and phone number of the PHC Grievance Coordinator that will be handling your grievance.

You will receive a written response/resolution to your grievance within thirty (30) calendar days of the date it was received by PHC.

The written response/resolution to your grievance will summarize your grievance and PHC's proposed resolution.

If you do not speak English fluently, you have the right to language translation when you are providing us with more information or are discussing a solution to your grievance.

You have the right to propose a resolution to the grievance.

You have the right to obtain representation by an advocate or legal counsel to assist you in filing and/or resolving your grievance. You may obtain information about legal counsel from several sources, including Legal Services of Northern California (LSNC). Refer to Section 7 of this form, for a list of locations and phone numbers of offices located in Solano, Yolo and Napa Counties.

You may request an expedited review of your Grievance. PHC will grant your request for an expedited review, if PHC medical staff determines that it involves an imminent and serious threat to your health, including, but not limited to potential loss of life, limb, or major bodily function. In the case of expedited review of grievances, PHC makes a decision and notifies you as expeditiously as the medical condition requires, but no later than three (3) calendar days from the date the expedited review was requested.

You do not have to use the PHC grievance process. You have the right to file a request for a State Fair Hearing with the California Department of Social Services within ninety (90) days of the date of the action that caused you to be dissatisfied. Refer to Section 5 of this form, titled State Fair Hearing Instructions for more information about filing a State Fair Hearing through the State Department of Social Services, State Fair Hearing Division.

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SECTION 5

State Fair Hearing Information - For members covered by Medi-Cal

There are three ways to request a State Fair Hearing:

BY TELEPHONE: You can call the State at 1-800-952-5253.

TDD by calling 1-800-952-8349

BY MAIL: You can send a Hearing Request form or your own written request for a State Fair Hearing to:

IN PERSON: You can turn in a Hearing Request form or your own written request at one of the local County offices listed below:

Solano County Medi-Cal Recipients

Yolo County Medi-Cal Recipients

Napa County Medi-Cal Recipients

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SECTION 6

Legal Services of Northern California

Legal Services of Northern California (LSNC) may provide legal assistance with grievance cases or State Fair Hearings. For information about the services that are offered through LSNC, please call the phone numbers listed below:

Solano County

Napa County

Yolo County

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