Member grievances and appeals

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 the Customer Care Center 800-407-4627 (TTY 711) 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.

We want to make this process as easy as we can for you. You are also welcome to have a relative, representative, or health care practitioner or provider represent you on your behalf. If you are a minor or under the care of a conservator or guardian, we will also allow you to register the grievance or appeal on the member’s behalf. We also offer help through the grievance and appeals process by providing translations services to those who:

• Are hearing impaired
• Have limited proficiency in English
• Are visually impaired or disabled
• Have variable literacy needs
• Have variable or alternative format needs

Anthem Medi-Cal follows State and Federal civil rights laws specific to nondiscrimination grievance requirements and does not discriminate against a member for filing a grievance or for requesting a State Hearing. Members believed to have been discriminated against can file a grievance with Anthem Medi-Cal at any time but are not required to file a discrimination grievance with AnthemMedi-Cal before filing a discrimination grievance directly with Department of Health Care Services (DHCS) Office for Civil Rights (OCR) or the Department of Health & Human Services (HHS) OCR as communicated in the member nondiscrimination notice.
 
Anthem Medi-Cal will timely acknowledge and resolve discrimination grievances within the appropriate grievance timeframes and provides members with an appropriate resolution. Anthem Medi-Cal has a designated discrimination grievance coordinator who is responsible for ensuring compliance with federal and state nondiscrimination requirements. The discrimination grievance coordinator is required to investigate grievances alleging any action that would be prohibited by, or out of compliance pursuant to federal or state nondiscrimination laws.
 
The discrimination grievance coordinator must:

• Answer questions and provide appropriate assistance to Anthem Medi-Cal staff and members pursuant to Anthem Medi-Cal’s state and federal nondiscrimination legal obligations.
• Advise Anthem Medi-Cal about nondiscrimination best practices and accommodating persons with disabilities.
• Investigate and process any American with Disabilities Act (ADA), Section 1557 of the Patient Protection and Affordable Care Act and or Government Code section 11135 grievances received by Anthem Medi-Cal.

Anthem Medi-Cal Grievance and Appeals Department (G&A) will prepare and forward all member grievances related to discrimination to the Anthem Medi-Cal’s discrimination grievance coordinator within two (2) days of mailing the member resolution letter. The information must include:

• The original complaint.
• The provider’s or other accused party’s response to the grievance.
• Contact information for Anthem Medi-Cal’s personnel responsible for investigations and responses to the grievance.
• Contact information for the member filing the grievance and for the provider or other accused party that is the subject of the grievance.
• All correspondence with the member regarding the grievance, including the grievance acknowledgement and grievance resolution letter(s) sent to the member.
• The results of Medi-Cal’s investigation, copies of any corrective action taken, and any other information that is relevant to the allegation of discrimination.

The Anthem Medi-Cal designated discrimination grievance coordinator is required to forward all grievances related to discrimination to DHCS OCR designated discrimination grievance email box within 10 calendar days of mailing the member resolution letter.