Complaints, Grievances & Appeals
Complaints, Grievances & Appeals
If you have a complaint regarding the quality of service or care you got, 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 a reasonable accommodation you need such as an American Sign Language interpreter.
- You are having trouble getting an appointment, or 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 plan 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 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.
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.
To make an internal complaint, call Customer Service at 1-877-723-4795. You can make the complaint at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about.
- If there is anything else you need to do, Customer Service will tell you.
- You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
Attn: Grievance and Appeals
Santa Clara Family Health Plan
6201 San Ignacio Ave
San Jose, CA 95119
- Use our online Member Grievance Form.
- Fax to: 408-874-1962
- All of our doctors' offices and service providers can give you the form or we can mail one to you. You can give the completed form to our plan provider or send it to us at the address above.
You can tell Medicare about your complaint
You can send your complaint to Medicare using the Medicare Complaint Form.
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/TDD 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. 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 emergency, you disagree with SCFHP Cal MediConnect’s decision about your complaint, or SCFHP Cal MediConnect has not resolved your complaint after 30 calendar days.
Here are two ways to get help from the Help Center:
• Call 1-888-HMO-2219. Individuals who are deaf, hard of hearing, or speech-impaired can use the toll-free TTY number, 1-877-688-9891. The call is free.
• Visit the Department of Managed Health Care’s website.
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 http://www.hhs.gov/ocr for more information.
You may also contact the local Office for Civil Rights office at:
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
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.
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. The phone number for Livanta is 1-877-588-1123.
Yes. Your doctor or other provider can make the complaint for you. Also, someone besides your doctor or other provider can make the complaint for you, but first you must complete an "Appointment of Representative" form. The form gives the other person permission to act for you.
- If the complaint comes from someone besides you or your doctor or other provider, we must get the completed Appointment of Representative form before we can review the complaint.
For more information on making complaints, see Chapter 9 of your SCHFP Member Handbook. The Member Handbook can be found in Member Materials on our website.
Yes. Ask us for a copy by calling Customer Service at 1-877-723-4795.
You can call us 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 get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP Compliance Department:
Toll Free: 1-877-723-4795
TTY/TDD: 1-800-735-2929 or 711
Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
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, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
(8:00 a.m. - 8:00 p.m.
Monday - Friday)
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) depends on contract renewal. CMS (the Centers for Medicare & Medicaid Services) must approve SCFHP Cal MediConnect each year. You can continue to get health coverage as a member of our plan only as long as we continue to offer the SCFHP Cal MediConnect Plan for the year in question and CMS renews its approval of the plan. Even if SCFHP leaves the program, you will not lose health coverage. If SCFHP decides not to continue for the next calendar year, we must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
Last updated 12/28/2018