Filing a complaint or appeal

There are two different types of complaints. You can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by our plan. An external complaint is filed with and reviewed by an organization that is not affiliated with our plan. If you need help making an internal and/or external complaint, you can call the Cal MediConnect Ombuds Program at 1-855-501-3077 (TTY: 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m.

To make an internal complaint, you can do one of the following:

• Fill out and submit an online Grievance and Appeal Form:

English
Español
Tiếng Việt
Tagalog
中文

• Call SCFHP Cal MediConnect Plan Customer Service toll free at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. If there is anything else you need to do, SCFHP Cal MediConnect Plan Customer Service will tell you. We have free interpreter services for people who do not speak English.
• Complete and mail our Grievance and Appeal Form:

English
Español
Tiếng Việt
Tagalog
中文

Mail completed forms to:

Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Or fax completed forms to: 1-408-874-1962

• Write your complaint and send it to us. If you put your complaint in writing or if the complaint is about quality of care, we will respond to your complaint in writing.
  
  Mail letter to:

Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Or fax letter to: 1-408-874-1962

• Visit the SCFHP office and speak with one of our representatives.

Refer to Chapter 9, Section J2 of the SCFHP Cal MediConnect Plan Member Handbook for more information about internal complaints. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

SCFHP Cal MediConnect Plan can help you fill out this form. You can do one of the following:

• Call us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
• Write a letter and mail it to:
  Attn: Grievance and Appeals Department
  Santa Clara Family Health Plan
  PO Box 18880
  San Jose, CA 95158

• Visit the SCFHP office and speak with one of our representatives.

We will help you in any way we can and answer any questions that you have. We can also help you in your preferred language.

You can also call Medicare directly for help with problems. Here are two ways to get help from Medicare:

• Call: 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY: 1-877-486-2048. The call is free.
• Visit the Medicare website (www.medicare.gov).

You can get help from the Quality Improvement Organization (QIO)

Our state has an organization called Livanta Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Livanta BFCC-QIO is not connected with our plan.

Contact Livanta BFCC-QIO if you have a problem with the quality of care you have received (a complaint), you think your hospital stay is ending too soon, or you think your home health care, skilled nursing facility care or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon.

To contact Livanta BFCC-QIO, you can do one of the following:

• Call: 1-877-588-1123, available 24 hours a day, 7 days a week. TTY users should call 1-855-887-6668.
• Write to:
  Livanta BFCC-QIO
  10520 Guilford Road, Suite 202
  Annapolis Junction, MD 20701-1105
  
  
• Visit the website at www.livanta.com

You can tell Medicare about your complaint

You can send your complaint to Medicare. The Medicare Complaint Form is available at on Medicare’s website.

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-­486-2048. The call is free.

You can tell Medi-Cal about your complaint

The Cal MediConnect Ombuds Program also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. The Cal MediConnect Ombuds Program is not connected with us, with any insurance company, or health plan.

The phone number for the Cal MediConnect Ombuds Program is 1-855-501-3077 (TTY: 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m. The services are free.

You can tell the California Department of Managed Health Care about your complaint

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 1-877-723-4795 (TTY:711) 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.

As a Medi-Cal beneficiary:

You can request a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing.

In most cases you have 120 days to ask for a State Hearing after the “Your Hearing Rights” notice is mailed to you.

There are two ways to ask for a State Hearing:

1. You may complete the “Request for State Hearing” on the back of the notice of action. You should provide all the requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:
• The county welfare department at the address shown on the notice.
• To the California Department of Social Services:
  State Hearing Division
  PO Box 944243, Mail Station 9-17-37
  Sacramento, CA 94244-2430
  
  
• To the State Hearings Division at fax number 1-916-651-5210 or 1-916-651-2789.
2. You can call the California Department of Social Services at 1-800-952-5253. TTY users should call 1-800-952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.

For more information on requesting a State Hearing, refer to Chapter 9 in your SCFHP Cal MediConnect Plan Member Handbook. You can view the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

You can file a complaint with the Office for Civil Rights

You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. The phone number for the Office for Civil Rights is 1-800-368-1019. TTY users should call 1-800-537-7697. The call is free. You can also visit Department of Health and Human Services’ Office for Civil Rights’ website for more information.

You may also contact the local Office for Civil Rights office at:

Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103

Customer Response Center: 1-800-368-1019
Fax: 1-202-619-3818
TDD: 1-800-537-7697
Email: ocrmail@hhs.gov

You may also have rights under the Americans with Disability Act and under any state laws that may apply. You can contact the Cal MediConnect Ombuds Program for assistance. The phone number is 1-855-501-3077 (TTY: 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m. The call is free.

You can file a complaint with the Quality Improvement Organization

When your complaint is about quality of care, you also have two choices:

• If you prefer, you can make your complaint about the quality of care directly to the Quality Improvement Organization (without making the complaint to us).
• Or you can make your complaint to us and to the Quality Improvement Organization. If you make a complaint to this organization, we will work with them to resolve your complaint.

The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.

In California, the Quality Improvement Organization is called Livanta Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO). Livanta BFCC-QIO is not connected with our plan.

Call Livanta BFCC-QIO 24/7 at 1-877-588-1123 (TTY: 1-855-887-6668).

Yes. A family member, friend, trusted person, or doctor can file the appeal or grievance for you. But you must first give them legal permission to act for you. This is called appointing a representative. To appoint a representative, fill out the Appointment of Representative (AOR) form. You can get the form on the Medicare’s website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or in Member Materials. You must give us a copy of the signed form. You may cancel the appointment of your representative at any time. The form must be renewed each year.

Instructions for filling out the AOR can be found in the Member Materials page. You may cancel the appointment of your representative at any time. You can also call SCFHP Cal MediConnect Plan Customer Service to request a form be mailed to you.

SCFHP will also accept an equivalent written notice so long as it includes the following information:

• Your name, address, and telephone number
• The name, address and telephone number of the person you would like to appoint as your representative
• Your Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI), or SCFHP member ID number
• Your appointed representative’s professional status or how you are related to him or her (i.e., friend, family member, lawyer, etc.)
• What subject(s) you would like the person to know or speak on (i.e., a complaint, any coverage decision, a medical appeal only, etc.)
• A statement that gives the person permission to act on your behalf and that you allow this person to receive your protected health information (PHI)
• A statement by the person being appointed that he or she accepts the appointment
• A signature from you and the representative along with the date you both signed the document

You may send the completed and signed AOR form or equivalent written notice to:

Attn: AOR Review Team
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Or fax it to 1-408-874-1965.

You can call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect Plan by contacting the SCFHP Grievance and Appeals Department:

Call:

Toll free: 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Fax: 1-408-874-1962

Write:
Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

To file a complaint about SCFHP Cal MediConnect Plan to Medicare, click here to use the form on Medicare’s website. Or you can call Medicare 24/7 at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) to ask for help.

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Plan Customer Service for help.

If you are more comfortable speaking a language other than English, Santa Clara Family Health Plan can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

• You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
• When you go to the doctor, interpreters are available 24-hours a day.
• You can ask for SCFHP Cal MediConnect Plan materials in English, Spanish, Simplified Chinese, Tagalog, and Vietnamese.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.