Grievance and appeal process
Submit a Grievance—Medi-Cal and Healthy Kids
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 resolve your questions or concerns. If the problem is not resolved, call our Customer Service. They will work with you to fix the problem and if they cannot solve the problem, the Grievance and Appeals Department will help to resolve the issue.
Any kind of complaint about your physician, medical group, hospital, or any other health care provider issue that you cannot solve with that health care provider is called a grievance. A grievance is also called a complaint.
Any complaint about a Notice of Action (denial letter) you have received telling you that a medical or pharmacy service has been denied, deferred, or modified is called an appeal.
If you receive a Notice of Action, you have 60 days from the date on the Notice of Action to file an appeal with SCFHP. If your health care provider files the appeal, SCFHP requires your written consent.
Services or benefits that were previously authorized will continue during the appeal process if your request for continuation is filed:
- Within 10 calendar days of the Notice of Action, or
- Before the date SCFHP intends to terminate services, explained through the Notice of Action
You can also file a complaint that is not about a Notice of Action. You may file your complaint with SCFHP at any time, regardless of the date that the issue or action occurred which caused you to be dissatisfied.
To request a copy of the Grievance and Appeal Process to be mailed to you, please call Customer Service at 1-800-260-2055.
If you are assigned to the Kaiser Permanente network, please call their Member Services Department at 1-800-464-4000.
To submit a problem or report a grievance:
- Call us toll-free at 1-800-260-2055 (TTY: 711)
- Visit our office location to speak to a Customer Service Representative in person
- Write our Grievance Manager at:
Santa Clara Family Health Plan
6201 San Ignacio Ave.
San Jose, CA 95119
- Enter a grievance using our online grievance forms:
Message from the California Department of Managed Health Care
The California Department of Managed Health Care is responsible for regulating healthcare service plans. If you have a grievance against your health plan, you should first contact Santa Clara Family Health Plan (SCFHP) at 1-800-260-2055 and use SCFHP'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 SCFHP, 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 TTY/TDD line (1-877-688-9891) for the hearing- and speech-impaired.
The department's website has complaint forms, IMR application forms, and instructions online. The above services are available to SCFHP's members at no cost.
Message from the California Department of Health Care Services
The Medi-Cal members have the right to request a State Hearing when a claim for medical assistance is denied or is not acted upon with reasonable promptness. A State Hearing must be requested within 120 calendar days from the Notice of Appeal Resolution (appeal denial notice). You may call the State Department of Social Services toll free at 1-800-952-5253 to request a State Hearing. TTY/TDD users may call 1-800-952-8349. A State 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 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.