¿Tiene una queja o queja? Podemos ayudarle a resolverlo.

¡Su satisfacción es importante para nosotros! Si usted tiene un problema con la Alianza, tiene derecho a presentar una queja. Esto también se llama presentar una apelación o una queja. Una apelación es cuando usted solicita la revisión de una “Determinación Adversa de Beneficios.”

Las determinaciones adversas de beneficios pueden ser:

  • Una denegación o autorización limitada de un servicio solicitado.
    • Esto puede incluir:
      • Decisiones basadas en el tipo o nivel de servicio
      • Necesidad médica
      • Cuidado y ajuste adecuados
      • La eficacia de un beneficio cubierto
  • Una reducción, suspensión o terminación de un servicio previamente autorizado.
  • Una denegación, total o parcial, del pago de un servicio.
  • Una falta de prestación de servicios de manera oportuna.
  • El hecho de que la Alianza no resuelva una queja o apelación dentro de los plazos requeridos.
  • Una denegación de su solicitud para ver a un proveedor fuera de la red de la Alianza.
  • Una denegación de su solicitud para disputar responsabilidad financiera.

We are here to help you!

If you have a problem with your health care services, please call:

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.

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

Report a Problem

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

1. Call the Alliance Member Services Department

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: Monday – Friday, 9 am – 4:30 pm, closed from 12pm – 1 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

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

Online Grievance Form coming soon.

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.

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:

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. 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.

Additional Options for Members with a Complaint

Here are some other ways to file a complaint:

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 or 1-877-371-2222 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 http://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 at 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
MS 19-37
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