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.

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.

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.

When will the health plan respond?

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

Expedited grievances

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.

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?

You may file an appeal within 60 calendar days of the date on the letter we sent to tell you of our decision. You might be able to file an appeal even if 60 days have passed since we made our first decision. Tell us in your written request why you could not file within the 60 days allowed.

Your doctor or other provider can make an appeal for you. Someone other than your doctor can also make an appeal for you, but they must first complete an Appointment of Representative form. If you want someone else to file an appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

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

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, 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.

You can get help from the Quality Improvement Organization

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).

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 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 request 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. 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 in English or Spanish if someone is helping you with your IMR, or call 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

    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 Hearing at the following number. 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?

Your doctor or other provider can make an appeal for you. Someone other than your doctor can also make an appeal for you, but they must first complete an Appointment of Representative form. If you want someone else to file an appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

Fast (expedited) appeals

You or your doctor can ask for a fast (expedited) appeal if you are asking about care you have not yet received and waiting on a decision on a standard appeal could cause serious harm to your health or hurt your ability to function. You cannot get a fast appeal if your request is about payment for care you have already received.

When will I receive a decision?
  • Expedited (Fast) Part D Prescription Drug Appeal: 72 hours
  • Standard Part D Prescription Drug Appeal: 7 calendar days (pre-service appeals) or 14 calendar days (payment appeals)
  • Expedited (Fast) Part C Appeal: 72 hours
  • Part C Standard Pre-Service Appeal: 30 calendar days
  • Part C Payment Appeal: 60 calendar days

We can take extra days to make a decision in some cases under certain circumstances. If we decide to take extra days to make the decision, we will send you a letter that explains why we need more time.

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.

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.

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 may be required if a person other than you or your prescribing physician is appealing on your behalf
Can I still get services while my appeal is being processed?

If we decide to reduce or stop coverage for a prior approved Medi-Cal service you are already receiving, you can request to continue those services during the appeal process. You must make this request within 10 calendar days of our notice to you that we will reduce or stop coverage of the service or the effective date of that notice, whichever is later.

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 Independent Review Entity (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 item or service (including a non-Part D drug):

If we don’t decide in your favor, your case will be sent to the Independent Review Entity (IRE) for a decision. We’ll send you a letter to tell you if this happens.

Note: If your appeal is about an item or service covered by both Medicare and Medi-Cal and we do not decide in your favor, your case will be sent to the IRE, and you may ask for an Independent Medical Review (IMR) and/or request a State Hearing. If the IRE and the state make different decisions, we’ll follow the decision that is most favorable to you.

To request an IMR:

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

To request a State Hearing:

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.


H6229_19_38074_U CMS Accepted 01/01/2019 Page Last Updated On 05/17/2019