![]() ![]() Complaint forms and instructions can be accessed online at DHMC. The hearing and speech impaired may use the California Relay Service's toll-free numbers-80 (TTY) or 1-88 (TTY)-to contact the department. The DMHC's Health Plan Division has a toll free telephone number-1-80-to receive complaints regarding health plans. ![]() The DMHC is responsible for regulating health care service plans. In addition to the complaint processes described above, you may also contact the California Department of Managed Health Care (DMHC). You must contact your Health Plan to arrange the hearing to review your case. A hearing before the Appeals and Grievance Committee will be scheduled within 10 working days. ![]() If your health plan's decision is not in your favor, and you disagree with the decision, you may request an expedited review by the Appeals and Grievance Committee. You will receive written confirmation of the decision within two working days. Your health plan will make a decision on your expedited appeal and will notify you of the decision within 72-hours after the review commences. You should specifically state that you are requesting an expedited appeal because you believe your health might be seriously jeopardized by waiting for the standard appeal process. You or your practitioner may file a verbal or written request for an expedited appeal. If not, your appeal will be processed within the 30 standard days. If you request an expedited appeal, your health plan's health services department will evaluate your request and medical condition to determine if your appeal qualifies as expedited, which will be processed within 72-hours. In some cases, you have the right to an expedited appeal when a delay in the decision might pose an imminent and serious threat to your health including, but not limited to, possible life, limb, or major bodily function. Your health plan makes every effort to process your appeal as quickly as possible. Please submit a copy of your denial notice and a brief explanation to the address indicated by your health plan coverage card, or call your health plan's Customer Service department who will document and research your request. There are two methods of appeals: Standard or Expedited.Ī standard appeal will be processed within 30 working days. Your request may be verbal or in writing. Your health plan requests that you submit your appeal within 60 days of your medical group's/IPA's final determination. If you believe that the resulting determination is not correct, you, or a representative appointed by you to act on your behalf, has the right to appeal through your health plan. Member's Rights to Appeal a Denied Service & Appeal Process The Peer Review Organization review process is designed to help stop any improper practices. Peer Review Organizations are groups of doctors and health professionals that monitor the quality of care provided. If you are concerned about the quality of care you have received, you, or a representative appointed by you to act on your behalf, may also file a complaint with the local Peer Review Organization, California Medical Review, Inc. ![]() Peer Review Organization Complaint Process Please refer to your health plan member materials for more detailed instructions on how to file a complaint/grievance. This process is separate from the appeal process described in the "Member's Rights to Appeal a Denied Service & Appeal Process" section below. The grievance process allows the member to file a complaint with the health plan about issues other than a denied service. The health plan refers to this process as a "grievance". You, or a representative appointed by you on your behalf, may file a written quality complaint with your health plan. Health Plan Quality Complaint "Grievance"
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