Complaints, grievances & appeals
If you have an issue about whether a service or supply is covered, about the way a service or supply is covered, received a bill for care, or have a complaint regarding the service or supply you got from us or our providers, please let us know right away. Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) Customer Service is here for you.
Call SCFHP Cal MediConnect Customer Service toll free at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. We have free interpreter services for people who do not speak English.
You have different options for reporting problems and complaints. Select your area of concern for more information:
- Medical care appeals – Concerns about benefits or coverage for medical care, behavioral health, and long-term services and supports
- Pharmacy (Part D) appeals – Concerns about benefits or coverage for drugs (Part D)
- Complaints & grievances – Complaints about quality of care, waiting times, customer service, etc.
You can also submit a complaint using the Grievance and Appeal Form. “Making a complaint” is also called “filing a grievance.” Visit Filing a Grievance or Appeal page to complete and submit the online form or download a copy of the form.
For more information on what to do if you have a problem or a complaint, see Chapter 9 in your SCFHP Cal MediConnect Member Handbook. You can view the SCFHP Cal MediConnect Member Handbook in Member Materials.
Who can I call for help asking for coverage decisions or making an appeal?
You can ask any of these organizations for help:
- Call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
- 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. This call is free. The Cal MediConnect Ombuds Program helps people enrolled in Cal MediConnect with service or billing problems. You can also get information on their website at www.healthconsumer.org.
- Call Medicare 24/7 at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048). This call is free. You can also visit their website at www.medicare.gov.
- Call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-408-350-3200 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. HICAP is an independent organization. Their services are free. And HICAP is not connected with any insurance company or health plan.
- Call the Department of Managed Health Care (DMHC) Help Center at 1-888-466-2219 (TTY: 1-877-688-9891), Monday through Friday, 8 a.m. to 6 p.m. DMHC is responsible for regulating health plans. The DMHC Help Center can help you with appeals and complaints against your health plan about Medi-Cal services.
- Call the Quality Improvement Organization (QIO) 24/7 at 1-877-588-1123 (TTY: 1-855-887-6668). Our state has an organization called Livanta Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO). If you have a problem with the quality of care, think your hospital stay is ending too soon, or think your home health care, skilled nursing facility care, or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon, contact Livanta BFCC-QIO to make a complaint.
- Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf.
- Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision, file a complaint, or make an appeal. If you want a friend, relative, or other person to be your representative, call SCFHP Cal MediConnect Customer Service and ask for the “Appointment of Representative” form. You can also get the form by visiting www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or in Member Materials. The form gives the person permission to act for you. You must give SCFHP a copy of the signed form.
- You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. You can ask for a legal aid attorney from the Health Consumer Alliance at 1-888-804-3536. However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.
You can give legal permission to have someone represent you. If you want a friend, relative, or other person to be your representative, call SCFHP Cal MediConnect Customer Service and ask for the “Appointment of Representative (AOR)” form. You can also get the form on the Medicare website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or in Member Materials. The form gives the person permission to act for you. 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.
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 your behalf (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 get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP Grievance and Appeals Department:
Toll free at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
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 to Medicare, click here to use the online 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 Customer Service for help.
If you speak a language other than English, language assistance services, free of charge, are available to you. Call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY:711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.