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Member Grievance Form

GRIEVANCE FORM

SCFHP Contact Information

Phone: 1-800-260-2055
TTY/TDD: 1-800-735-2929
Fax: 1-408-874-1962

This form is optional. Santa Clara Family Health Plan can help you fill out this form or you may file a grievance verbally by calling us at 1-800-260-2055, 8:30 a.m. to 5 p.m., Monday – Friday. TTY/TDD users should call 1-800-735-2929. Or, someone will contact you by phone as soon as we receive this form. We will assist you in any way we can and answer any questions that you have. We can help you in any language.

If completed by somebody other than the member, an Authorized Representative Form (ARF) form is required.

The Department of Managed Health Care requires Santa Clara Family Health Plan to inform you of the following:

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 1-800-260-2055 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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

As a Medi-Cal beneficiary:

You can request a State Hearing. If you decide to request a hearing, you must do so within 90 days of the mailing of your notice. Please contact Santa Clara Family Health Plan for the forms that you need. They are also available from the Santa Clara County Department of Social Services.

Information about the State Hearing process is also available by writing:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430

Or by calling 1-800-952-5253 or TDD 1-800-952-8349.