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Filing a complaint

If you have a complaint regarding any aspect of Santa Clara Family Health Plan (SCFHP), please let us know right away. The formal name for “making a complaint” is “filing a grievance.” Here are some examples of the kinds of problems handled by the complaint process:

  • You are unhappy with the quality of care, such as the care you got in the hospital.
  • You think that someone did not respect your right to privacy, or shared information about you that is confidential.
  • A health care provider or staff was rude or disrespectful to you.
  • SCFHP staff treated you poorly.
  • You think you are being pushed out of the plan.
  • You cannot physically access the health care services and facilities in a doctor or provider’s office.
  • Your provider does not give you the reasonable accommodation you need such as an American Sign Language interpreter.
  • You are having trouble getting an appointment, or are waiting too long to get it.
  • You have been kept waiting too long by doctors, pharmacists, or other health professionals, or by Customer Service or other SCFHP staff.
  • You think the clinic, hospital, or doctor’s office is not clean.
  • Your doctor or provider does not provide you with an interpreter during your appointment.
  • You think we failed to give you a notice or letter that you should have received.
  • You think the written information we sent you is too difficult to understand.
  • You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal.
  • You believe that, after getting a coverage or appeal decision in your favor, we are not meeting the deadlines for approving or giving you the service or paying you back for certain medical services.
  • You believe we did not forward your case to the Independent Review Entity (IRE) on time.

If you need help, please call SCFHP Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also get help or information from the Cal MediConnect Ombuds Program by calling 1-855-501-3077 (TTY: 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m. Or by visiting their website at www.healthconsumer.org.

Different types of complaints

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.

How to submit an internal complaint

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

  • Call SCFHP Customer Service 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, Customer Service will tell you.
  • 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 to:

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

  • Use our online Member Grievance Form
  • Fax to: 1-408-874-1962
  • Visit our office. A representative will help document your complaint.
    Santa Clara Family Health Plan
    6201 San Ignacio Ave.
    San Jose, CA 95119

Read Chapter 9, Section 10.1 of the SCFHP Cal MediConnect Member Handbook for more information about internal complaints. Find a copy of the Member Handbook in Member Materials.

How to submit an external complaint

You can tell Medicare about your complaint

You can send your complaint to Medicare. The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx.

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 or 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 (DMHC) is responsible for regulating health plans. You can call the DMHC Help Center for help with complaints about Medi-Cal services. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, if you are in severe pain, if you disagree with SCFHP Cal MediConnect’s decision about your complaint, or if SCFHP Cal MediConnect has not resolved your complaint after 30 calendar days.

Here is how you can get help from the DMHC Help Center:

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. You can also visit https://www.hhs.gov/ocr/index.html  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.

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).

Can someone else make the complaint 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

How can I find out the status of my complaint?

You can call us at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 711.

How to get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect

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:

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

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) to ask for help.

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