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Report a Problem / Make a Complaint

If you encounter an issue during a health care appointment, receive an inappropriate bill for care, or have a complaint regarding the service you receive from us or one of our providers, please let us know right away. Problems can sometimes be resolved on the same day we are made aware of them.

To submit a problem report or grievance, do one of the following:

Grievance Process

SCFHP wants you to be satisfied with your health care. If you have questions regarding your care, we encourage you to speak with the health care professional treating you. In most cases, they can provide answers right away and hopefully resolve your questions or concerns. If the problem is not resolved, call SCFHP’s Member Services. They will work with you to fix the problem and if we cannot solve the problem, you may file a formal complaint or grievance. Services previously authorized will continue during the grievance process.

If you receive a Notice of Action (denial letter) you have 90 days from the date on the Notice of Action to file an appeal with SCFHP. You may also request a State Fair Hearing from the State Office of the Ombudsman within 90 days.

You can also file a grievance that is not about a Notice of Action. You must file your grievance with SCFHP or the provider within 180 days from the day the incident or action occurred which caused you to be dissatisfied.

  • Download our Grievance Process.
  • To request a hardcopy of the Grievance Process, please contact our Member Services Department at 1-800-260-2055

Report Fraud

FRAUD is a dishonest act done on purpose.

Examples of Member Fraud are:

  • Providing false information when applying for programs or services
  • Getting prescriptions with the intent of abusing or selling drugs
  • Letting someone else use your health care ID card

If you suspect fraud, you should report the situation to:

  • Chief Compliance Officer
    Santa Clara Family Health Plan
    210 East Hacienda Ave
    Campbell, CA 95008
  • You may call our Compliance Hot Line: 1-408-874-1450
  • Send a fax to: 408-874-1970
  • Email us at compliance@scfhp.com or click here to fill out our contact form

Be sure to have as much information as possible. The more information you have, the better the chance the case will be successfully reviewed and resolved.

Message from the California Department of Managed Health Care

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 contact Santa Clara Family Health Plan at 1-800-260-2055 and use Santa Clara Family 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 Santa Clara Family Health Plan, or a grievance that has remained unresolved for more than 30 calendar 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 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-HMO-2219) for complaints and a TDD line (1-877-688-9891) for the hearing and speech impaired. (You can find further instructions, complaint forms, and IMR application forms on the department’s website).

Message from the California Department of Health Services

Medi-Cal members have the right to request a State Fair Hearing at any time during the grievance and appeal process. You may call the State Department of Social Services toll free at 1-800-952-5253 to request a State Fair Hearing. A State Fair Hearing is an administrative procedure at which you can present your concern directly to the State of California. If you decide to request a State Fair Hearing, you may represent yourself at the hearing, or another person (such as an attorney, friend, relative or any person you choose) may represent you. The Department of Social Services can help you obtain a Legal Aid, free of charge, to help with your State Fair Hearing.