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File a grievance or appeal

If you have an issue about whether a service or supply is covered, about the way a service or supply is covered, or received a bill for care, or have a complaint regarding the service or supply you got from us or one of our providers, please let us know right away. Santa Clara Family Health Plan (SCFHP) Customer Service is here for you.

To submit a grievance or appeal to SCFHP, you can do one of the following:

  • Call:
    Toll Free: 1-877-723-4795 (TTY: 711)
    8 a.m. to 8 p.m., Monday through Friday.
    We have free interpreter services for people who do not speak English.

Mail completed forms or letters to:

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

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

  • Or visit the SCFHP office and speak with one of our representatives:
    Santa Clara Family Health Plan
    6201 San Ignacio Ave.
    San Jose, CA 95119

For more information on what to do when you have a problem or a complaint, see Chapter 9 in your SCFHP Cal MediConnect Member Handbook. You can view the Member Handbook in Member Materials.

Can I get help filing an appeal or grievance?

Santa Clara Family Health 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:

Santa Clara Family Health Plan
6201 San Ignacio Ave.
San Jose, CA 95119

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

Can someone else fill out the form for me?

Yes. A family member, friend, other trusted person, or doctor or other provider 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, call Customer Service and ask for the “Appointment of Representative” 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. You must give us a copy of the signed form. Please note that an AOR is valid for one year from the date you and the representative sign the form. You may cancel the appointment of your representative at any time.

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, and
  • 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

File a complaint about SCFHP Cal MediConnect directly with Medicare

To file a complaint about SCFHP Cal MediConnect 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).

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 telephone your health plan at 1-877-723-4795 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 an IMR, the IMR process will provide an impartial view 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 website 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 have filed an appeal about Medi-Cal covered services and items, and your appeal was denied. 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 916-651-5210 or 916-651-2789.
  1. 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.

Accessibility

You can ask for published materials for free in other formats, such as large print, braille, or audio. Call Customer Service for help.

If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) depends on contract renewal.

Last updated 01/08/2020

H7890_15083W Accepted