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Report a Problem

Submit a Grievance - Medi-Cal and Healthy Kids

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:

  • Call us toll-free at 1-800-260-2055 or TTY/TDD 1-800-735-2929
  • Visit our office location to speak to a Member Services Representative in person
  • Write our Grievance Manager at Santa Clara Family Health Plan, 210 East Hacienda Avenue, Campbell, CA 95008
     
  • Enter a grievance using our online grievance forms:

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  • Complete and mail our Member Grievance Form:

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Cal MediConnect members, please visit the Cal MediConnect Appeals & Grievances page.

 

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 TTY/TDD line (1-877-688-9891) for the hearing and speech impaired.

The department's Internet 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 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 at 1-800-260-2055 at least 7 business days before the appointment. We will contact your doctor to verify your need.

Download our Grievance Process.

 

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.

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