Grievance
Process
Grievance
Definition
A
grievance is defined as a written or oral expression of dissatisfaction
regarding HealthCare Advantage of California, Inc. (“HA of CA”) and/or
a provider, including complaints, disputes, quality of care concerns,
requests for reconsideration or appeals made by a member or the member’s
representative.
Grievance
Process
HA
of CA has a grievance procedure for receiving and resolving your grievances
involving HA of CA and providers. A grievance may be submitted up to 180
calendar days following any action or incident that is the subject of
the member's dissatisfaction. You may submit a grievance to HA of CA in
writing, in person, by telephone, by facsimile, by e-mail, or online at
this web site. At the member’s request, we will mail the member
a grievance form and a copy of our Grievance Procedure. A Customer Service representative can help you
fill out the grievance form.
To
submit a grievance, you may call us at 1-800-454-1755. Completed grievance
forms may be submitted online through a secure means at this web site
or must be mailed or delivered to:
HealthCare Advantage
of California, Inc.
861 SW 78th
Ave., Suite 200
Plantation, FL 33324
You
may also submit a grievance in person at this same address.
We
will send you written acknowledgment of our receipt of a grievance within
five (5) calendar days. We will respond in writing with our resolution
to a grievance within thirty (30) calendar days of receipt.
Expedited
Review of Urgent Grievances
HA
of CA also maintains a process for expedited review of urgent grievances.
You have the right to an expedited review for cases involving an imminent
and serious threat to the health of the member, including but not limited
to severe pain, potential loss of life, limb, or major bodily functions.
The member or the member’s provider may initiate the request.
Call 1-800-454-1755 and tell the representative you are requesting
expedited review of an urgent grievance. We will notify your provider
of the decision in no more than 72 hours and we will send you a written
statement regarding the disposition or pending status of the grievance
within the same 72 hours from our receipt of the grievance.
Additional
Review
If
you are dissatisfied with our response to a grievance, you may submit
a request to HA of CA for voluntary mediation or binding arbitration within
sixty (60) days of receipt of our response. These processes are described
in your Combined Evidence of Coverage and Disclosure Form.
You may also call us for information about how to submit a voluntary
mediation or arbitration request.
You
may file a grievance with the Department of Managed Health Care after
completing the HA of CA grievance process or voluntary mediation. You may also file a grievance with the Department
of Managed Health Care after participating in the HA of CA grievance process
or voluntary mediation for thirty (30) days.
Independent
Medical Review
You
may request an independent medical review ("IMR") of disputed
services from the Department of Managed Health Care if you believe that
health care services have been improperly denied, modified, or delayed
by HA of CA.
The
IMR process is in addition to any other procedures or remedies that may
be available to you. You pay no application or processing fees of any
kind for IMR. You have the right to provide information in support of
the request for IMR. HA of CA will
provide you with an IMR application form with any grievance disposition
letter that denies, modifies, or delays health care services. A decision
not to participate in the IMR process may cause you to forfeit any statutory
right to pursue legal action against HA of CA regarding the disputed health
care service.
The
IMR process is described in your Combined Evidence of Coverage and Disclosure
Form or you may call us for information on how to submit an IMR request.
Review
by the Department of Managed Health Care
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 (1-800-454-1755) 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 www.hmohelp.ca.gov
has complaint forms, IMR application forms and instructions online.
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Related
Links
California
Department of Managed Health Care |
