For more information about how to ask for coverage determinations and submit grievances and appeals, see Chapter 9 in your Member Handbook (Evidence of Coverage) or call Member Services.
To find out how many appeals, grievances, and exceptions have been filed with our plan over the past year or to get the status of your request, call Member Services at 1-855-817-5785 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. The call is free.
What is a grievance?
A grievance is a type of complaint that does not involve payment, denial or discontinuation of services by our health plan or our network providers.
You might file a grievance if you have a problem with things such as:
- The quality of your care during a hospital stay
- You feel you are being encouraged to leave your plan
- Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room
- The way your doctors, network pharmacists or others behave
- Not being able to reach someone by phone or get information you need
- Lack of cleanliness or the condition of the doctor's office
When can a grievance be filed?
You can make the complaint at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about.
You may only ask for a “fast” (expedited) grievance under certain circumstances.
Under Part D, you have the right to an expedited grievance if you ask for a “fast” coverage determination or “fast” appeal and we decide that the “fast” decision you requested should be processed under the standard timeframe.
For all other requests (not involving a Part D drug), you have the right to an expedited grievance if you ask for a “fast” decision to cover the item or service or “fast” appeal and we decide that the “fast” decision you requested should be processed under the standard timeframe. You also have the right to an expedited grievance if we decide to take additional days to decide on your standard request for coverage or your request for a standard appeal and you disagree with our decision.
You will be notified in writing if you have the right to a “fast” grievance.
Who can file a grievance?
You may file a grievance. Or, someone else may file the grievance for you with your permission.
Appointing a representative
If you want someone else to file the grievance for you, fill out the Appointment of Representative form and send it to us with your grievance.
A legal surrogate under court order or state law may also be able to file an appeal. Examples of a legal surrogate may include a legal guardian or an individual acting under a power of attorney.
Where can a grievance be filed?
File grievances in writing to:
Anthem Blue Cross Cal MediConnect Plan
Complaints, Appeals and Grievances
4361 Irwin Simpson Road
Mason, OH 45040
File grievances over the phone by calling Member Services at 1-855-817-5785 (TTY: 711). Monday through Friday from 8 a.m. to 8 p.m. The call is free.
If you feel you have used all your options with us, you may file a complaint directly with Medicare.
When will the health plan respond?
We have thirty (30) days from the filing date to respond to your grievance.
H6229_20_117631_U CMS Accepted 01/01/2020 Page Last Updated on 01/01/2020