You can also write us at:
	Partnership HealthPlan of California
	360 Campus Lane, Ste 100
	Fairfield, CA 94534
	Attn: Grievance Unit
Our fax number is: (707) 863-4306

You have a right to appoint someone to represent you regarding your appeal. Please fill out Section I of the form provided below. Your representative should fill our Sections II through IV. You may mail or fax in your completed form to Partnership HealthPlan of California. Our contact information is listed above.

Click below to open the form:
CMS' Appointment of Representation Form (FORM CMS-1696)

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For Part D Grievances & Appeals

PartnershipAdvantage provides an appeals and grievance process for our members to ensure you get answers to any concerns or problems you may encounter.

GRIEVANCES:

If you have concerns or problems with PartnershipAdvantage which are not about payment or drug coverage, you have the right to file a grievance. You may file a grievance by contacting the PartnershipAdvantage Member Services Department toll free at (866) 264-3626 from 8 am to 8 pm, 7 days a week. Members with hearing and/or speech impairments can call through the California Relay Service at (800) 735-2929, or dial 711.

You can also send a completed PartnershipAdvantage Appeal & Grievance Form, or write a letter, directly to:

PartnershipAdvantage
360 Campus Lane, Suite 100
Fairfield, CA 94534
Attn: Grievance Unit

You will receive a written letter telling you that PartnershipAdvantage received your grievance, the name and telephone number of the Resolution Specialist that is handling your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within 30 days of PartnershipAdvantage receiving your grievance.

APPEALS:

As a member, you can file an appeal if PartnershipAdvantage makes a decision to not pay for, not approve, or stop a service you think should be covered or provided to you. This could include denials for drugs or involving payment for services (including co-payments and billing issues or reimbursement) you received or believe you should receive under the PartnershipAdvantage pharmacy program. You or your appointed representative must file the appeal within sixty (60) calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice). To appeal a decision, please contact PartnershipAdvantage Member Services Department by calling toll free (866) 264-3626 from 8 am to 8 pm, 7 days a week. Members with hearing and/or speech impairments can call through the California Relay Service (CSR) at (800) 735-2929, or dial 711.

When filing an appeal under Part D, also called a "Redetermination Request", you can also use the form below to request an appeal:
Model Redetermination Request Form

You can send your appeal in writing to:

PartnershipAdvantage
360 Campus Lane, Suite 100
Fairfield, CA 94534
Attn: Grievance Unit

We will review your appeal and send you a letter telling you our decision within seven (7) days of receiving your appeal request. If you think your health could be seriously harmed by waiting for a decision about the drug, you can request a faster decision which is issued within 24 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include an independent review entity; hearings before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review.

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