Your satisfaction with your health care is important to us! Please call our Member Services department first if you have a problem with your health care services. We want to help you. You can call the Member Services department at 510-747-4567 in the 510 area code. Outside of the 510 area code, you can contact us toll-free at 1- 877-932-2738.
You may also inform the Alliance about your problem in a letter or by fax using the fax number supplied on the grievance form, below. Regardless of how you contact us, the Grievance Process will work the same. These are the steps of how your grievance is handled by the Alliance.
Grievance Form
Step 1: Grievance Process
Tell us about your grievance. The Member Services department will ask about the problem and get started on solving it. In some cases, we will be able to solve it immediately. In other cases, we may have to get more information before finding a solution. When this happens, we will send you a letter within Five (5) calendar days of receiving your grievance. The letter will tell you the status of your grievance and the name of a person you can contact if you have any questions. A Grievance and Appeal Coordinator will contact you by letter with a solution to your problem in 30 calendar days or less.
Step 2: Appeal Process
If you are unhappy with the solution from Step 1, you may file an appeal with the Alliance. This must be done in writing through a letter explaining why you disagree with the resolution proposed in Step 1 and provide information that supports your reason for appealing. Your appeal letter must be submitted within 10 calendar days of the date of the date of the resolution letter. (see Step 1).
The Alliance will schedule your appeal for a hearing. You will be able to participate in the appeal either in person, by telephone or in writing. Appeals will be heard by members of the Alliance's Compliance Committee. The Alliance will inform you of the final decision by phone and in writing within 48 hours of the hearing's conclusion. Again, we will work to resolve your grievance and appeal within 30 days.
Throughout this process you have the right to:
- Be treated with respect
- Give us your views
- Have materials translated
- Receive interpreter services
- Represent yourself or have someone else represent you
- Propose a solution
- Look at the file documenting your grievance
- See pertinent plan policy materials
The California Department of Managed Health Care wants you to know:
"The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against the Alliance, you should first telephone us at 510-747-4567 and use our grievance process before contacting the DMHC. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the Alliance, or a grievance that has remained unresolved for more than 30 days, you may call DMHC for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. DMHC also has a toll-free number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. DMHC's Internet web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online."
To reach the DMHC via this website, you can click on their website name listed above.
Other Grievance and Appeals Options:
In addition to the using the Alliance process or one of the DMHC options listed above, there are other methods for having your complaints resolved.
Medi-Cal Managed Care Ombudsman (Medi-Cal Members Only): If you feel the Alliance has not solved your problem, you may call this State office at 1-888-452-8609. Their office hours are from 8:00 a.m. and 5:00 p.m. They offer help to Medi-Cal members in managed care plans.
State Fair Hearings (Medi-Cal Members Only): You may also file a request for a State Fair Hearing at any time within 90 days of the action that you are complaining about. You may ask Member Services for help in filing a State Fair Hearing request. You may also call the Department of Social Services at 1-800-952-5253. If you need a teletypewriter (TDD), call 1-800-952-8349. The request can be sent to: California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 19-37, Sacramento CA 94244-2430.
Please Note: Call our Member Services department at any time if you need somebody to explain any part of the grievance process. Call 510-747-4567, 8 a.m. to 6 p.m., Monday through Friday.
