Grievance & Appeals Process

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.

Grievances:

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
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.

Instead of using our Appointment of Representative form, you can also send a written statement, signed and dated by both you and your representative.

The statement must include:

  • Your name, address, and telephone number
  • Your HICN or Medicare Identifier (ID) Number
  • Your representative’s name, address and telephone number (this could be your provider)
  • A statement that you are authorizing the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative:"I [your name] appoint [name of representative] to act as my representative in filing a grievance regarding the ____________. I authorize disclosure of individually identifying information to [name of representative]"
  • You must sign and date your statement
  • A statement by your representative that he or she accepts the appointment as your representative: "I {name of representative} agree to act as a representative for [member name] in filing a grievance regarding the ____________"
  • Your representative must sign and date both statements

Your representative can also provide appropriate legal paper supporting his or her status as your authorized representative.

When can a grievance be filed?

You may file a grievance within sixty (60) calendar days of the date the incident happened. There is no filing limit for complaints concerning quality of care. The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.

When will the health plan respond?

We have thirty (30) days from the filing date to respond to your grievance.

Expedited grievances

If you disagree with our decision to take an extension on your appeal request, or on our initial decision to process your expedited (fast) request in the normal time frame, you can ask for an expedited (fast) grievance. You have the right to request an expedited grievance (or fast review) in these cases. We’ll give you our decision within 24 hours.

Where can a grievance be filed?

File grievances in writing to:

Appeals and Grievances
Anthem Blue Cross MediConnect Plan
4361 Irwin Simpson Road
Mail Stop OH0205-A537
Mason, OH 45040-9549

File grievances over the phone by calling Member Services at 1-855-817-5785 (TTY 711).

Fax: 1-888-458-1406

Appeals:

What is an appeal?

An appeal is when you ask us to review a decision we made about coverage of a service, the amount we paid or will pay for a service, or the amount you must pay for a service.

You might file an appeal if:

  • We refuse to cover or pay for services you think we should cover
  • We or one of our network providers refuses to give you a service you think should be covered
  • We or one of our network providers cuts back on services you’ve been getting
  • You think we’re stopping your coverage too soon
How and when can an appeal be filed?

The way you file an appeal depends on the service.

You may file an appeal within 60 calendar days of the date of the notice of our first coverage decision.

Call Member Services or submit appeals in writing to:

Appeals and Grievances
Anthem Blue Cross MediConnect Plan
4361 Irwin Simpson Road
Mail Stop OH0205-A537
Mason, OH 45040-9549

Fax: 1-888-458-1406

Where can an appeal be filed?
  • Mail your written appeal to:

    Appeals and Grievances
    Anthem Blue Cross Cal MediConnect Plan
    4361 Irwin Simpson Road
    Mail Stop OH0205-A537
    Mason, OH 45040-9549

  • Call Member Services at 1-855-817-5785 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time
  • Fax your written appeal to 1-888-458-1406
  • Submit appeals or grievances online to SeniorG&AIntake@anthem.com. Please include the following information:
    • Member Name
    • Member ID
    • Contact Number
    • Brief description of grievance/appeal:

**NOTE: Please upload any documents in support of your grievance/appeal

Where to get additional help about a Medi-Cal service

You can get help from the Cal MediConnect Ombuds program

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

You can get help from the Health Insurance Counseling and Advocacy Program

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 local HICAP phone number is 1-408-350-3200.

Getting help from Medicare

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 (www.medicare.gov).

You can get help from the California Department of Managed Health Care

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.

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.

Independent Medical Review (IMR)

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 (not including IHSS) 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 waive the requirement that you first follow Anthem Blue Cross Cal MediConnect Plan’s appeal process in extraordinary and compelling cases.

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 request an IMR:

Fill out the Complaint/Independent Medical Review (IMR) Application Form available at www.dmhc.ca.gov/FileaComplaint/IndependentMedical
ReviewComplaintForm.aspx
or call the DMHC Help Center at 1-888-466-2219. TDD 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 if someone is helping you with your IMR. You can get the form at www.dmhc.ca.gov/FileaComplaint/IndependentMedical
ReviewComplaintForm.aspx
or by calling the DMHC Help Center at 1-888-466-2219. TDD 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: 916-255-5241

For non-urgent cases involving Medi-Cal services (not including IHSS), you will receive an IMR decision from the DMHC within 30 days of receipt of your application and supporting documents. For urgent cases that involve an immediate or serious risk to your health, you will receive an IMR decision within three to seven days.

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.

State Hearing

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 120 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, California 94244-2430

To the State Hearings Division at fax number 916-651-5210 or 916-651-2789.

2. You may make a toll-free call to request a State Fair Hearing at the following number. If you decide to make a request by phone, you should be aware that the phone lines are very busy.

Call the California Department of Social Services at 1-800-952-5253. TDD 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.

Who can file an appeal?
  • You may file an appeal.
  • Someone else may file the appeal for you on your behalf.
When will I receive a decision
  • Part D Drug Appeal: 7 calendar days
  • Part C (Non-Part D) Drug Appeal: 30 calendar days
  • Part C Standard Service Appeal: 30 calendar days
  • Part C Payment Appeal: 60 calendar days
Appointing a representative

If you want someone else to file the appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

Instead of using our Appointment of Representative form, you can also send a written statement, signed and dated by both you and your representative.

The statement must include:

  • Your name, address, and telephone number
  • Your HICN or Medicare Identifier (ID) Number
  • Your representative’s name, address and telephone number (this could be your provider)
  • A statement that you are authorizing the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative:"I [your name] appoint [name of representative] to act as my representative in filing an appeal regarding the ____________. I authorize disclosure of individually identifying information to [name of representative]"
  • You must sign and date your statement
  • A statement by your representative that he or she accepts the appointment as your representative: "I {name of representative} agree to act as a representative for [member name] in filing an appeal regarding the ____________"
  • Your representative must sign and date both statements

Your representative can also provide appropriate legal paper supporting his or her status as your authorized representative.

What do I include with my appeal?
  • If your appeal is about a Part D drug: Your completed Redetermination Request Form
  • Your name, address and member ID number
  • Your reasons for appealing
  • Any information or evidence (documents, medical records) to support your appeal
  • An Appointment of Representative (AOR) form if a person other than you or your prescribing physician is appealing on your behalf

If your appeal is about a Part C (Non-Part D) drug, Medicare-covered service or Medicaid-covered service

  • You don’t need a special appeal form. Just submit your reason in writing.
  • Any information (documents, medical records) to support your appeal
  • An Appointment of Representative (AOR) form if you choose to have someone else submit the appeal on your behalf
Can I still get services while my appeal is being processed?

Part D drug: Not applicable

Part C (Non-Part D) drug, Medicare-covered service (Part C) or Medi-Cal (Medicaid) -covered service. You or your PCP must request continuation of previously approved services during the appeal process

What can I do if the appeal decision is unfavorable?

If your appeal was about a Part D drug:

If we don’t decide in your favor, we’ll send you a letter to tell you. You will have to reach out directly to the IRE at this stage of the process.

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Ave., Suite 703
Pittsford, NY 14534-1302
Fax number: 585-425-5301
Customer Service: 585-348-3400

If your appeal was about a Part C (Non-Part D) drug or a Standard Service Appeal:

If we don’t decide in your favor, your case is auto-forwarded to the independent review entity (IRE). We’ll send you a letter to tell you if this happens. You will have to reach out directly to the IRE at this stage of the process.

Note: If there is an adverse determination for a service covered by both Medicare and Medicaid, it will be auto-forwarded to the IRE, and you may also ask the Help Center at the Department of Managed Health Care (DMHC) for an Independent Medical Review or request a State Fair Hearing. If both the IRE and the state make decisions, we’ll follow the decision that is most favorable to you.

Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Fax: 916-255-5241
Customer Service: 1-888-466-2219
TDD users should call 1-877-688-9891

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430
Fax number 916-651-5210 or 916-651-2789
Customer Service 1-800-952-5253
TDD users should call 1-800-952-8349.

What happens next?

If you appeal, we will review our decision. If any of the services you requested are still denied after our review, CMS will send your case to a reviewer outside of our health plan. This is to give you a new, fair review. If you disagree with that decision, you will have more appeal rights. You will be told about those appeal rights if this happens.

Fast decisions/expedited appeals

You have the right to ask for and get expedited (fast review) decisions affecting your medical treatment and pharmacy coverage in time-sensitive situations. A time-sensitive situation is a time when waiting for a decision to be made in our normal time frame could seriously harm your life, health, or ability to get back your maximum function.

If your health requires a quick response, you may ask us to make a fast decision. We have 72 hours to respond with a fast decision. For Medical appeals only (non-Part D), we can take up to 14 more days if you ask us to give you an extension so you can send us additional information or if we need to get additional information before making our decision.

We will give you a fast appeal if:

  • We or your physician decide your situation is time-sensitive
    -OR-
  • Any physician calls or writes in support of your request for an expedited review

For non-urgent requests, we have 7 calendar days to respond to Part D Pharmacy appeals, and 30 calendar days to respond to Medical appeals.

Please note: Requests to pay you back for payments you have made, or to appeal the denial of payment for services that already happened, cannot be expedited.


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