Grievance And Appeals

Your point of view matters! 

We want you to have the best care and service possible. If you have a problem while using your PHC Medi-Cal plan, you have the right to file a Grievance or an Appeal. When you tell us about your problem, it helps us improve care for all members. We will never discriminate or retaliate against you for filing a case. 

Your point of view matters! We want you to have the best care and service possible. If you have a problem while using your PHC Medi-Cal plan, you have the right to file a Grievance or an Appeal. When you tell us about your problem, it helps us improve care for all members. We will never discriminate or retaliate against you for filing a case. 

 
FILE NOWWHO CAN FILETYPES OF CASESWHAT TO EXPECTTIMEFRAMESHOW TO FILESTATE HEARINGS

 

​  Who can file a case?

Any PHC member can file a case. You must be an eligible member at the time the problem happened or on the date your benefits were denied. 

If you want someone to represent you, they must have your approval. This is done by completing an Authorization Representative form. Examples of Authorized Representatives are parents of children, adult children of elderly parents, neighbors, and/or friends. A provider can file an Appeal on your behalf without the Authorization Representative form.  This is because they are disputing services that they need to treat you. However, you will need to complete the Authorized Representative form if the provider is filing a Grievance on your behalf.

 Types of cases

What is a Grievance?
Are you unhappy with your service? A Grievance is a request for PHC to review a problem with services you received from your provider or PHC. An example of a Grievance is waiting too long to receive an appointment with your doctor. There is no time limit for filing a Grievance.

What is an Appeal?
An Appeal is a request for PHC to review a decision made about a benefit that has been denied, limited, or stopped. It also includes not paying for covered services. An example of an Appeal is if you disagree with a denied surgery. You must file your Appeal within 60 calendar days from the date on the Notice of Action (NOA) letter.

     What to Expect

The Grievance & Appeals Process

Once your case has been filed, you are assigned a Grievance & Appeals Case Analyst who will investigate your problem. A letter is mailed to you on or before the 5th day to let you know your case has been received. During the process, the Grievance & Appeals Case Analyst will call you to ask questions about the reported problem. Towards the end of the process, you will receive a phone call and a letter from the Grievance & Appeals Case Analyst to let you know about the result of the investigation.

If you file an Appeal, you have the right to submit evidence that shows why your benefit should be approved. Your evidence must be received within the first 10 days of filing your case. If your case is approved for an expedited review, your evidence must be received within the first 24 hours. See Timeframes for more information. Your Grievance & Appeals Case Analyst will let you know if your evidence is needed sooner.

For more information on our Grievance & Appeals process, see Policy CGA024
For more information on our Member Discrimination Grievance Process, see Policy CGA022

Timeframes

Most Grievances and Appeals are investigated within 30 calendar days. A case can be extended for an additional 14 calendar days if the additional time will help your case.

If you feel that waiting 30 calendar days will seriously threaten your health or life, you can ask for an expedited review of your case. If a PHC Medical Director agrees that your health or life is at risk, the case will be reviewed within 72 hours.

How to file a Grievance or Appeal

1-800-863-4155 or TTY 1-800-735-2929
Call Member Services Monday through Friday from 8 a.m. - 5:00 p.m. for help with filing a case. Ask Member Services for an interpreter or other language assistance services if you need help communicating.  

Are you a Member?  File Now

The "File Now" link will take you to the PHC Member Portal. You will need to login, then file your case. Call Member Services if you need assistance. 


OTHER WAYS TO FILE

Calling Member Services or filing online are the best ways to file a case. However, you can file a case using other options below. 

You can complete the Member Grievance & Appeals Form to describe your problem.  Tell us what happened and how we can help. Explain why you are not happy with your experience or why your benefit should be approved. Send the completed Member Grievance & Appeals Form to PHC to file your case.  You can send it by mail or fax. You can also file it in person or give it to your doctor. Use the contact information below.

 Mail
Partnership HealthPlan of California
ATTN: Grievance & Appeals Department
4665 Business Center Drive, Fairfield, CA 94534

State Hearings

If you are unhappy with the decision on any Appeal, you can file a State Hearing. A State Hearing is when a member requests an Administrative Law Judge (ALJ) from the Department of Social Services to review PHC’s Appeal decision. The ALJ will review PHC’s Appeal decision, evidence, and testimony before making a new decision. PHC Member Services can help you file a State Hearing with the Department of Social Services. You can also file it using a method below.

Phone - California Department of Social Services
1-800-743-8525
1-800-952-8349 (TTY)

 Mail
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430

 Fax - California Department of Social Services

1-916-651-2789

Online
www.cdss.ca.gov/hearing-requests
Click here to file your case online

You can represent yourself at a State Hearing. You can also get free legal help from the Legal Services of Northern California. You can contact them at 1-888-354-4474 or www.lsnc.net. They can find an office near you.
 
The state Medi-Cal Managed Care Ombudsman Office is available to assist you with any questions. Call 1-888-452-8609 or TTY: 1-800-735-2929 Monday - Friday from 8 a.m. to 5 p.m.