Do you have a complaint or grievance? We can help you solve it.

Your satisfaction is important to us! If you have a problem with the Alliance, you have the right to make a complaint. This is also called filing an appeal or a grievance. An appeal is when you ask for review of an “Adverse Benefit Determination.”

Adverse Benefit Determinations can be:

  • A denial or limited authorization of a requested service.
    • This can include:
      • Decisions that are based on the type or level of service
      • Medical necessity
      • Appropriate care and setting
      • The effectiveness of a covered benefit
  • A reduction, suspension, or termination of a previously authorized service.
  • A denial, in whole or in part, of payment for a service.
  • A failure to provide services in a timely manner.
  • The failure of the Alliance to resolve a grievance or appeal within the required time frames.
  • A denial of your request to see a provider outside of the Alliance network.
  • A denial of your request to dispute financial liability.

We are here to help you!

If you have a problem with your health care services, please call:
Alliance Member Services Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4567
Toll-Free: 1.877.932.2738
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Alameda Alliance Wellness Member Services Department
Seven (7) days a week, 8 am – 8 pm, including holidays
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

We will ask you about the problem and start solving it. In some cases, we will be able to solve it right away. In other cases, we may need more information before finding a solution. The Alliance will review your grievance or appeal and respond within 30 calendar days, or sooner, based on your health condition.

If you have a grievance or appeal, you may file it by phone, online, or by filling out the Alliance Member Grievance Form. Your provider may also file an appeal for you.

Alameda Alliance Wellness members can submit a complaint directly to the Centers for Medicare & Medicaid Services (CMS) at https://www.medicare.gov/my/medicare-complaint.

Alliance Medi-Cal Members

  • You can file a grievance with the Alliance any time after the event that caused your grievance.
  • You must file an appeal of an action within 60 calendar days of the date services or benefits were denied.

For more information, please view your Alliance Medi-Cal Member Handbook.

Alliance Group Care Members

Alameda Alliance Wellness Members 

  • You can file a grievance with the Alliance any time after the event that caused your grievance. 

For more information, please view your Alameda Alliance Wellness Member Handbook. 

Report a Problem (GRIEVANCE FORM)

There are four (4) ways to file a grievance:

1. Call the Alliance Member Services Department
Alliance Member Services Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4567
Toll-Free: 1.877.932.2738
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Alameda Alliance Wellness Member Services Department
Seven (7) days a week, 8 am – 8 pm, including holidays
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

2. In-Person by visiting our office:
Alameda Alliance for Health
1240 South Loop Road
Alameda, CA 94502
Hours of Operation: Monday – Friday, 8 am – 5 pm
Lobby Hours: Tuesday, Wednesday, and Thursday, 9 am – 11 am and 2 pm – 4 pm

3. Write a letter describing the problem and mail it to the Alliance.
Alameda Alliance for Health
ATTN: Member Services Department
P.O. Box 2818
Alameda, CA 94501-0818

Alameda Alliance Wellness members can write to:
Alameda Alliance Wellness
ATTN: Grievances and Appeals
1240 South Loop Road, Alameda, CA 94502 

4. Download and complete the Grievance form in your preferred language:
English | Spanish | Chinese | Vietnamese | Tagalog | Farsi

Click here to access the online Grievance form.

Alameda Alliance Wellness Members can submit a grievance directly to the Centers for Medicare & Medicaid Services  (CMS) at https://www.medicare.gov/my/medicare-complaint. 

Urgent Grievance or Appeal

If you think that waiting 30 days will harm your health, be sure to say why when you file your grievance or appeal. You may then be able to get an answer within 72 hours if the complaint is an immediate and serious threat to your health.

For Alameda Alliance Wellness members, Expedited Grievances will be resolved within 24 hours. Please note that grievances are only accepted as Expedited for two reasons, when the grievance is regarding our decision to take an extension or when the grievance is regarding our decision to downgrade an appeal.

Your Grievance and Appeal Rights

The Alliance will always treat you with respect. You have the right to give the Alliance your views, or provide documents that support your views, or propose a solution. You may speak for yourself or have someone else speak for you, including a lawyer. Using the grievance and appeals process does not rule out any potential legal rights or remedies that you may have.

You may ask to look at or get a copy of our records that relate to your case. You or your provider may get a copy of the benefit provision, guideline protocol, or criteria used to make a denial decision. You will receive these copies at no cost.

To request a copy, please call:
Alliance Member Services Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4567
Toll-Free: 1.877.932.2738
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Alameda Alliance Wellness Member Services Department
Seven (7) days a week, 8 am – 8 pm, including holidays
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Appeals

When you file your appeal, you can still continue to receive services until the process is complete. The Alliance must give you a decision within 30 calendar days or within 72 hours if your problem is an immediate and serious threat to your health. For Alameda Alliance Wellness members Standard Part B and D appeals, the Alliance must give you a decision within 7 days. If the Alliance denied your treatment because it was experimental or investigational, you do not have to take part in the Alliance’s appeal process before you apply for an Independent Medical Review (IMR). You must ask for the IMR within six (6) months after the Alliance sends you a written response to your appeal.

Appeal Process for Medi-Cal Members

You may have received a Notice of Action (NOA) from the Alliance. Medi-Cal Members have 60 days from the date on the NOA to file an appeal with the Alliance.

Appeal Process for Alliance Group Care Members

You may have received a NOA from the Alliance. Alliance Group Care members have 180 days from the date on the NOA to file an appeal with the Alliance.

Appeal Process for Alameda Alliance Wellness Members 

If we make a coverage decision and you aren’t satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we made. 

You may have received a Notice of Action (NOA) from the Alliance. Alameda Alliance Wellness members have 65 days from the date on the NOA to file an appeal with the Alliance. 

Prescription Drug (Rx) Appeal form:
Download the Request for Redetermination of Medicare Prescription Drug Denial form in your preferred language:
English |Spanish | Chinese | Vietnamese | Tagalog | Farsi 

Additional Options for Members with a Complaint

Here are some other ways to file a complaint:

Alliance Member Services Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4567
Toll-Free: 1.877.932.2738
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Alameda Alliance Wellness Member Services Department
Seven (7) days a week, 8 am – 8 pm, including holidays
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

The California Department of Managed Health Care (DMHC)

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 1-510-747-4567 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. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department 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. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov  has complaint forms, IMR application forms and instructions online.

Independent Medical Review (IMR)

An Independent Medical Review (IMR) is a review of your case by doctors who are not part of the Alliance. You can ask for an IMR from the Department of Managed Health Care (DMHC). In most cases, you must complete the Alliance appeal process before you apply for an IMR with DMHC. However, if the Alliance initially denied your treatment because it was experimental or investigational, you do not have to take part in the Alliance appeal process before you apply for an IMR. You must ask for the IMR within 6 months after the Alliance sends you a written response to your appeal. If the IMR is decided in your favor, the Alliance must give you the service or treatment you asked for. There is no cost for this process.

You can apply for an IMR if the Alliance:

  • Denies, changes, or delays a service or treatment because it was determined as not medically necessary.
  • Will not cover an experimental or investigational treatment for a serious medical condition.
  • Will not pay for emergency or urgent medical services that you have already received.

To request an IMR, please contact:

Department of Managed Health Care
Toll-Free: 1.888.466.2219
People with hearing and speaking impairments (TDD): 1.877.688.9891
California Relay Service (CRS): 1.800.735.2929

For more information, or to view and download forms, please visit the DMHC website.

Additional Options for Medi-Cal Members with a Complaint

In addition to the using the Alliance or Department of Managed Health Care (DMHC) options, there are also other ways to resolve your complaint.

Medi-Cal Managed Care and Mental Health Office of the Ombudsman

The Medi-Cal Managed Care and Mental Health Office of the Ombudsman can look into and solve problems. The Ombudsman can help members with urgent enrollment and dis-enrollment problems. The Ombudsman can also offer information and referrals.

For more information, please call:

Medi-Cal Managed Care and Mental Health Office of the Ombudsman
Toll-Free: 1.888.452.8609

State Fair Hearings

If you would like to request a State Fair Hearing please mail or call to request a form.

California Department of Social Services
State Hearing Division
P.O. Box 944243, 9-17-433
Sacramento, CA 94244-2430
Toll-free: 1.800.952.5253
People with hearing or speaking impairments (TDD): 1.800.952.8349

You can ask for a State Fair Hearing within 120 days from the action you have a complaint about. If you and your treating provider want to continue your treatment, you must ask for a State Fair Hearing within 10 days from receiving an appeal response letter from the Alliance, or before the date your services will stop.

Legal Help

You may speak for yourself at the state hearing or have someone else speak for you, such as a family member, friend or lawyer. You may be able to get legal help through Alameda County or a legal service agency at no cost.

For more information, please contact:

Bay Area Legal Aid
Toll-Free: 1.800.551.5554
www.baylegal.org

ADDITIONAL OPTIONS FOR ALAMEDA ALLIANCE WELLNESS MEMBERS WITH A COMPLAINT

Sometimes it’s confusing to start or follow the process for dealing with a problem. This can be especially true if you don’t feel well or have limited energy. Other times, you may not have the information you need to take the next step. 

Help from the Health Insurance Counseling and Advocacy Program 
You can call the Health Insurance Counseling and Advocacy Program (HICAP). HICAP counselors can answer your questions and help you understand what to do about your problem. HICAP isn’t connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. The HICAP phone number is 1-800-434-0222. 

Help from the Medicare Medi-Cal Ombudsman Program
You can call the Medicare Medi-Cal Ombudsman Program and speak with an advocate about your health coverage questions. They may be able to offer free legal help. The Ombudsman Program isn’t connected with us or with any insurance company or health plan. Their phone number is 1-855-501-3077, and their website is www.healthconsumer.org. 

Help and information from Medicare
For more information and help, you can contact Medicare. Here are two ways to get help from Medicare: 

Help from the California Department of Health Care Services
The California Department of Health Care Services (DHCS) Medi-Cal Managed Care Ombudsman can help. They can help if you have problems joining, changing, or leaving a health plan. They can also help if you moved and are having trouble getting your Medi-Cal transferred to your new county. You can call the Ombudsman Monday through Friday, between 8:00 a.m. and 5:00 p.m. at 1-888-452-8609. 

Help from the California Department of Managed Health Care
Contact the California Department of Managed Health Care (DMHC) for free help. The DMHC is responsible for overseeing health plans. The DMHC helps people with appeals about Medi-Cal services or billing problems. The phone number is 1-888-466-2219. Individuals who are deaf, hard of hearing, or speech-impaired can use the toll-free TDD number, 1-877-688-9891. You can also visit DMHC’s website at www.dmhc.ca.gov. 

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 1.888.88A.DSNP (1.888.882.3767) 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. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department 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. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online. 

Fill out the IMR/Complaint Form available at: www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx 

Submit the IMR/Complaint Form and any attachments to the DMHC
Submit online: 
Submit by mail or fax: 
Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
FAX: 916-255-5241 

Get Help and Information from Livanta
Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Livanta is not connected with our plan. 

How to obtain an aggregate number of grievances, appeals and exceptions filed with Alameda Alliance Wellness?
Please call the Alameda Alliance Wellness Member Services Department. 

  • Call: 1.888.88A.DSNP (1.888.882.3767) 
  • Calls to this number are free. 8 am – 8 pm. (PST), 7 days a week, including holidays. 
  • People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929