Appeals

If you need help getting started, you can always call the Cal MediConnect Ombuds program. The Cal MediConnect Ombuds program can answer your questions and help you understand what to do to handle your problem.

The phone number for the Cal MediConnect Ombuds program is 1-855-501-3077. The services are free.

The Cal MediConnect Ombuds program is not connected with us or with any insurance company or health plan. They can help you understand which process to use.

You can also call the Health Insurance Counseling and Advocacy Program (HICAP). The HICAP counselors can answer your questions and help you understand what to do to handle your problem. HICAP is not connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. The HICAP phone number is 1-800-434-0222.

You can call Medicare directly for help with problems. Here are two ways to get help from Medicare:

• Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY: 1-877-486-2048. The call is free.
• Visit the Medicare website.

The following paragraph is a required disclosure under California Health & Safety Code Section 1368.02(b). In this paragraph, the term “grievance” means an appeal or complaint about Medi-Cal services, your health plan, or one of your providers.

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 1-855-817-5785 (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.

When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO). The QIO is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.

In California, the QIO is called Livanta. The phone number for Livanta is 1-877-588-1123
(TTY: 1-855-887-6668).

You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.

You can apply for an IMR if Anthem Blue Cross Cal MediConnect Plan:

• Denies, changes, or delays a Medi-Cal service or treatment because Anthem Blue Cross Cal MediConnect Plan determines it is not medically necessary.
• Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition.
• Will not pay for emergency or urgent Medi-Cal services that you already received.
• Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal.

You can ask for an IMR if you have also asked for a State Fair Hearing, but not if you have already had a State Fair Hearing on the same issue.

In most cases, you must file an appeal with us before requesting an IMR. See your handbook for information about Anthem Blue Cross Cal MediConnect Plan’s Level 1 appeal process. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.

If your treatment was denied because it was experimental or investigational, you do not have to take part in Anthem Blue Cross Cal MediConnect Plan’s appeal process before you apply for an IMR.

If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may not require you to first follow our appeal process depending on the facts of your case. You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.

To ask for an IMR:

• Fill out the Independent Medical Review (IMR) Application available at the DMHC Help Center website or call the DMHC Help Center at 1-888-466-2219. TTY users should call
  1-877-688-9891.
• If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
• Fill out the Authorized Assistant Form in English or Spanish if someone is helping you with your IMR, or call the DMHC Help Center at 1-888-466-2219. TTY users should call 1-877-688-9891.
• Mail or fax your forms and any attachments to:
  Help Center
  Department of Managed Health Care
  980 Ninth Street, Suite 500
  Sacramento, CA 95814-2725
  Fax: 1-916-255-5241

If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.

If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process.

If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have, and we continue to say no after a Level 1 appeal, you have the right to ask for a State Hearing.

In most cases you have 180 days to ask for a State Hearing after the date on your notice of appeal resolution. You have a much shorter time to ask for a hearing if you are currently getting treatment and you want to continue getting treatment.

There are two ways to request a State Hearing:

1. You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:
   • To the county welfare department at the address shown on the notice.
   • To the California Department of Social Services:
     State Hearings Division
     P.O. Box 944243, Mail Station 9-17-37
     Sacramento, CA 94244-2430
   • To the State Hearings Division at fax number 1-916-651-5210 or 1-916-651-2789.
2. You may make a toll-free call to request a State Hearing at the following number. Call the California Department of Social Services at 1-800-952-5253. TTY users should call
   1-800-952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.