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Home Healthcareplans Cal MediConnect Complaints, Grievances & Appeals

Complaints, Grievances & Appeals

Complaints, Grievances & Appeals

Medical Care

If you have problems with your benefits or coverage for your medical care, behavioral health care, or Long-Term Services and Supports (LTSS), please call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. You can also get help or information from the Cal MediConnect Ombuds Program by calling 1-855-501-3077 or by visiting their website at www.healthconsumer.org.

For detailed information on what to do if you have a problem or complaint, see Chapter 9 in your SCFHP Member Handbook.

Here is what you can do if you are in any of the following situations:

  • You think the plan covers medical care, behavioral health care, or long-term services and supports (LTSS) that you need but are not getting.

    What you can do:
    You can ask the plan to make a coverage decision. For information on asking for a coverage decision, see Benefits and Copays.
     
  • The plan did not approve care your doctor wants to give you, and you think it should have.

    What you can do:
    You can appeal the plan’s decision to not approve the care. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For information on beginning the appeal process, scroll down to the section that starts with, “Asking for a Level 1 Appeal.”
     
  • You got and paid for medical services or items you thought were covered, and you want the plan to reimburse you for the services or items.

    What you can do:
    You can ask the plan to pay you back. If you are asking to be paid back, you are asking for a coverage decision. See Benefits and Copays for information on asking for a coverage decision.
     
    • What if the plan says they will not pay?

      If you do not agree with our decision, you can make an appeal. Scroll down to the section on “Asking for a Level 1 Appeal.”
       
  • Your coverage for a certain service is being reduced or stopped, and you disagree with our decision.

    What you can do:
     If the coverage that will be stopped is for hospital care, special rules apply. Scroll down to the section on “Asking for a longer hospital stay.” 

    If the coverage that will be reduced or stopped is for home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, special rules apply. Scroll down to the section on “What to do if your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.”

    For all other cases where we tell you that medical care you have been getting will be reduced or stopped, you can appeal the plan’s decision. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Scroll down to the section on “Asking for a Level 1 Appeal” for what to do.

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