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ALLIANCE GRIEVANCE PROCESS FREQUENTLY ASKED QUESTIONS

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What is the Alliance Grievance System? This is the system for resolving member complaints and appeals about the services they get as Alliance members. Filing a complaint or appeal will not affect your health care coverage through the Alliance. Filing a complaint or appeal is your choice and your cooperation in the process is voluntary.

Why would I file a complaint? You could file a complaint if you:

Have delays in getting health care services that you think you need; such as medications, medical equipment, or doctor appointments

Are not happy with the services you got from a healthcare provider Are unhappy with any aspect of your healthcare. Disagree with us when we deny a service you feel you need Feel that a health care provider or the Alliance has not respected your privacy

Why would I file a complaint? Why would I file an appeal? Another reason why you might file a complaint is if we send you a Notice of Action. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred, or modified. This type of complaint is also called an appeal. If you receive a Notice of Action from us, you have sixty (60) days from the date on the Notice of Action to file an appeal with us. How do I file a complaint or appeal?

Call Member Services at: 1-800-700-3874 (TDD: 1-877-548-0857) Call the Grievance Coordinator at: 1-800-700-3874 ext. 5816. Mail the complaint form to the Grievance Coordinator at the Scotts Valley address

below.

Fill out an electronic complaint on our website, www.ccah-alliance.org Call for an appointment at any of our offices, Monday through Friday, 8 am to 5 pm:

Santa Cruz County 1600 Green Hills Road, Ste. 101

Scotts Valley, CA 95066 1-831-430-5500

Monterey County 950 East Blanco Road, Ste.101

Salinas, CA 93901 1-831-755-6000

Merced County 530 W. 16th Street, Ste. B

Merced, CA 95340 1-209-381-5300

What happens after I file my complaint or appeal? The Grievance Coordinator will send you a letter within 5 days after you file your complaint. This letter tells you we received your complaint. It explains your rights in the grievance process. How is my complaint or appeal resolved? Depending on the type of complaint you have, our staff may be able to resolve it very quickly. If this is not possible, we work with our own Alliance departments or providers to get it resolved. When will I receive a notice of resolution letter? We will send you a resolution letter within 30 days from the day we receive your complaint. What If my complaint involves a serious threat to my health? If your health problem is urgent, meaning it is a serious threat to your health, ask for an Expedited Review. If you request an Expedited Review, the Grievance Coordinator will let you know within 24 hours that your complaint has been received. A resolution will be completed within 3 days. An Expedited Review involves an imminent or serious threat to your health, including but not limited to severe pain, potential loss of life, limb, or major bodily function. What if I prefer to speak Spanish or Hmong? The Alliance has staff that speaks Spanish and Hmong and can help you file your complaint or appeal. What if I do not speak English, Spanish or Hmong? Please call us and we will arrange an interpreter for you through a telephone language line.

What if I have a complaint about my privacy? You can file with the Department of Health and Human Services – Office of Civil Rights at:

200 Independence Avenue SW Room 509F, HHH Bldg., Washington, D.C. 20201

What if I need help with my complaint or appeal?

You can authorize another person such as a family member or friend to help you. You can call the State Office of the Ombudsman at 1-888-452-8609 if you have Medi-

Cal.

You can call the California Office of the Patient Advocate at 1-866-HMO-8900 if you have Alliance Care IHSS or Medi-Cal Access Program (MCAP).

You can call the California State Consumer Affairs Department at 1-800-952-5210 if you need legal help.

Are there other ways to resolve my problem if I am a Medi-Cal member? If you have filed an appeal with the Alliance and received an appeal resolution letter, or if the Alliance did not resolve or respond to your appeal according to the timelines outlined above, you can ask for a State Hearing. You must ask for the hearing within 120 days from the date of receiving the Alliance’s appeal resolution letter. You can call the California Department of Social Services (DSS) at 1-800-952-5253 (TDD: 1-800-952-8349) to request a hearing or you can fax your request to DSS at 1-916-651-5210.

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You can also ask for a hearing at any of these local offices:

Santa Cruz County Human Services Department

1020 Emeline Street Santa Cruz, CA 95061

1-831-454-4117

Monterey County Department of Social Services 1000 S. Main Street, Ste 208

Salinas, CA 93901 1-831-755-4477

Merced County Human Services Agency 2115 W. Wardrobe Ave

Merced, CA 95341 1-209-385-3000

Are there other ways to resolve my problem if I am an Alliance Care IHSS or Medi-Cal Access Program (MCAP) member? 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 toll-free at 1-800-700-3874 or TDD 1-877-548-0857 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 IMR, the IMR process will provide an impartial review of medical decisions made by the health plan related to 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 Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

NONDISCRIMINATION NOTICE

Discrimination is against the law. Central California Alliance for Health (the Alliance) follows Federal civil rights laws. The Alliance does not discriminate, exclude people, or treat them differently because of race, color, national origin, age, disability, or sex. The Alliance provides:

• Free aids and services to people with disabilities to help them communicate better, such as:

Qualified sign language interpreters Written information in other formats (large

print, audio, accessible electronic formats, other formats)

• Free language services to people whose

primary language is not English, such as:

Qualified interpreters Information written in other languages

If you need these services, contact the Alliance Member Services Department between 8:00 a.m. to 5:00 p.m. by calling 1-800-700-3874. For the Hearing or Speech Assistance Line call 1-800-735-2929 (TTY: Dial 7-1-1).

HOW TO FILE A GRIEVANCE

If you believe that the Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Alliance Member Services Department. You can file a grievance by phone, in writing, in person, or electronically:

• By phone: Contact the Alliance Member Services Department between 8:00

a.m. to 5:00 p.m. by calling 1-800-700-3874. For the Hearing or Speech Assistance Line call 1-800-735-2929 (TTY: Dial 7-1-1)

• In writing: Fill out a complaint form or write a letter and send it to:

Grievance Department

1600 Green Hills Road, Suite 101

Scotts Valley, CA 95066

• In person: Visit your doctor’s office or the Alliance and say you want to file

a grievance.

• Electronically: Visit the Alliance’s website at https://www.ccah-alliance.org/Complaints.html.

OFFICE OF CIVIL RIGHTS

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by phone, in writing, or electronically:

• By phone: Contact the Office for Civil Rights between 8:00 a.m. to 5:00 p.m.

by calling 1-800-368-1019 (Note: this phone number is only in English. Please leave your name, phone number and the language you would like for them to return your call). For the Hearing or Speech Assistance Line call TTY/TDD 1-800-537-7697.

• In writing: Fill out a complaint form or write a letter and send it to:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

• Electronically: Visit the Office for Civil Rights Complaint website Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

https://www.ccah-alliance.org/Complaints.htmlhttp://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

LANGUAGE ASSISTANCE

English ATTENTION: If you speak another language, language assistance

services, free of charge, are available to you. Call 1-800-700-3874 (TTY:

1-800-735-2929).

Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos

de asistencia lingüística. Llame al 1-800-700-3874 (TTY: Llame al 1-800-

855-3000).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí

dành cho bạn. Gọi số 1-800-700-3874 (TTY: 1-800-735-2929).

Tagalog (Tagalog - Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng

mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-

800-700-3874 (TTY: 1-800-735-2929).

한국어 (Korean)

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로

이용하실 수 있습니다. 1-800-700-3874 (TTY: 1-800-735-2929)

번으로 전화해 주십시오.

繁體中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致

電 1-800-700-3874 (TTY: 1-800-735-2929）。

Հայ ե ր ե ն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խո ս ո ւ մ եք հայ ե ր ե ն , ապա ձեզ

ան վ ճ ար կար ո ղ են տր ամ ադ ր վ ե լ լե զ վ ակ ան աջ ակ

ց ո ւ թ յ ան ծառ այ ո ւ թյ ո ւ ն ն ե ր : Զան գ ահ ար ե ք 1-800-

700-3874 (TTY (հե ռ ատի պ)՝ 1-800-735-2929):

Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам

доступны бесплатные услуги перевода. Звоните 1-800-700-

3874 (телетайп: 1-800-735-2929).

(Farsi) فارسی شما برای رایگان بصىرث زبانی حسهیالث کنید، می گفخگى یفارس زبان به اگر: توجه

.بگیرید حماس (TTY: 1-800-735-2929) 3874-700-800-1 با . باشد می فراهم

日本語 (Japanese)

注意事項：日本語を話される場合、無料の言語支援をご利用いた

だけます。1-800-700-3874 (TTY: 1-800-735-2929）まで、お電話に

てご連絡ください。

Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev

pab dawb rau koj. Hu rau [1-800-700-3874] (TTY: [1-800-735-2929]).

(Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁੀਂ ਪੰਜਾਬੀ ਬਲਿੇ ਸ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱਚ ਸਾਇਤਾ ੇਵਾ ਤੁਸਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਸੈ। 1-800-700-3874 (TTY: 1-800-735-2929) 'ਤੇ ਕਾਲ ਕਰ।

(Arabic) العربیةبالمجان. احصل مقرب 4783-007-008-1 كل خدماث المساعدة اللغىیت حخىافرفإن

ملحىظت: إذا كنج حخحدد اذكر اللغت،

.(9292-537-008-1 : رقم هاحف الصم والبكم)

(Hindi) : आप आप प । 1-800-700-3874 (TTY: 1-800-735-2929) पर र ।

ภาษาไทย (Thai) :

1-800-700-3874 (TTY: 1-800-735-2929).

(Cambodian)

ប្រយ័ត្ន៖ បរ ើសិនជាអ្នកនិយាយ ភាសាខ្មែ , ប សវាជំនួយខ្មែនកភាសា

រោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំរ ើអ្នក។ ចូ ទូ ស័ព្ទ 1-800-700-

3874 (TTY: 1-800-735-2929)។

CREATING HEALTH CARE SOLUTIONS

Date Filed: __________________

Step 1: Complete the grid below with your Alliance information

Last Name: First Name:

Alliance ID#: Cell Phone#:

Date of Birth: Other Phone#:

Address:

City, State and Zip Code:

I have Alliance coverage through:

Medi-Cal Alliance Care IHSS Medi-Cal Access Program (MCAP)

I request an expedited review because this issue involves a serious threat to my health.

I asked the following person or provider to help me with my complaint or appeal:

Name of person: Relationship:

Step 2: Describe what happened or what action you are appealing

For appeals, what is the modified or denied authorization#:

For complaints, who is your complaint against? Provider Name:

When did this happen? Date:

Describe what happened:

Step 3: Sign and date this form

I certify that the statements made above are true and correct to the best of my belief: Signature:____________________________________ Date:_________________________

Step 4: Return this form via email, fax or regular mail:

Regular mail: Alliance Grievance Department, 1600 Green Hills Rd., Ste. 101, Scotts Valley, CA 95066 Email: grievancecoordinator@ccah-alliance.org, Fax: (831) 430-5569

Member Complaint & Appeal Form

mailto:grievancecoordinator@ccah-alliance.org