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/ Advantage D-SNP Grievances/Appeals

Advantage D-SNP Grievances/Appeals

What to do if you have a problem or concern with Health Plan of San Joaquin/ Mountain Valley Health Plan’s Dual Eligible Special Needs Plan (D-SNP):

  • You can call Health Plan’s Customer Service at 1-888-361-7526 (TTY) 711 and ask for a Member Complaint Form. If you need help filling out the form, Health Plan Customer Service can assist you.
  • File a Grievance/Appeal
    Our Customer Service Department 1-888-361-7526 (TTY) 711 is here to help you file your complaint or appeal, which can be submitted as a written statement or a completed form.
File a Grievance
File an Appeal
  • You can give the completed form to any Health Plan Provider or mail it to:
    Health Plan of San Joaquin / Mountain Valley Health Plan
    7751 South Manthey Road
    French Camp, CA 95231
  • You can fax the completed form to 1-209-942-6355 or email it to grievances@hpsj.com. You can file a grievance online. This form is for Advantage D-SNP as well as other Health Plan programs.
  • For some types of problems, you need to use the process for coverage decisions and making appeals.

    • Part C: Coverage Determination and Appeals

    • Part D: Coverage Determination and Appeals

      • You can call Health Plan’s Customer Service at 1-888-361-7526 (TTY) 711 and ask for a Member Complaint Form. If you need help filling out the form, Health Plan Customer Services can assist you.
      • File a Grievance
        Our Customer Service Department 1-888-361-7526 (TTY) 711 is here to help you file your complaint or appeal, which can be submitted as a written statement or a completed form. File a grievance online.
      • File an Appeal
        MedImpact 1-833-546-0796 (TTY) 711 is here to help you file your complaint or appeal, which can be submitted as a written statement or a completed form.

For other types of problems, you need to use the process for making complaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.

Long-Term Services and Supports:

  • If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609 for help.
  • For problems and concerns regarding eligibility determinations, assessments and care delivered by our contracted Community Based Adult Services (CBAS) centers or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below.

Community Based Adult Services (CBAS)

  • You can call Health Plan’s Customer Service at 1-888-361-7526 (TTY) 711 and ask for a Member Complaint Form. If you need help to fill out the form, Health Plan Customer Services can assist you.
  • You can give the completed form to any Health Plan Provider or mail it to:
    Health Plan of San Joaquin / Mountain Valley Health Plan
    7751 South Manthey Road
    French Camp, CA 95231
  • You can fax the completed form to 1-209-942-6355 or email it to grievances@hpsj.com. You can also file a grievance online. This form is for Health Plan Advantage D-SNP (HMO) as well as other Health Plan programs.

Help in Handling a Problem

You can contact Medicare. Here are two ways to get information directly from Medicare:

Get Help from an Independent Government Organization

We are always available to help you. But in some situations, you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information and offer guidance on what to do. The services of SHIP counselors are free. You can call SHIP at 1-800-434-0222.

Get Help and Information from DHCS

Get Help and Information from Medi-Cal

The Office of the Ombudsman Program can answer your questions and help you understand what to do to handle your problem. The Office of the Ombudsman is not connected with us or with any insurance company or health plan. They can help you understand which process to use.

Get Help and Information from Commence Health

Our state has an organization called Commence Health Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Commence Health is not connected with our plan.

How to obtain an aggregate number of grievances, appeals and exceptions filed with Health Plan of San Joaquin / Mountain Valley Health Plan Advantage D-SNP (HMO)?

Please call or write to Health Plan of San Joaquin / Mountain Valley Health Plan D-SNP Customer Service Department:

  • Call: 1-888-361-7526 (TTY) 711. Calls to this number are free. 8 a.m.- 5 p.m. (PST), 7 days a week, including holidays.
  • Fax: 1-209-942-6355
  • Mail: Health Plan of San Joaquin / Mountain Valley Health Plan
    7751 South Manthey Road
    French Camp, CA 95231
  • Email: grievances@hpsj.com

Health Equity Analysis of Prior Authorization Use

CMS requires an annual health equity analysis to examine the impact of the use of prior authorization for members with social risk factors.

The analysis compared two populations at the plan level using data from the prior contract year regarding coverage of items and services. The two populations included:

Population A: All members enrolled in with Health Plan D-SNP

Population B: All Advantage D-SNP members with a disability status

The analysis includes the following metrics for each of the populations:

(A) The percentage of standard prior authorization requests that were approved, aggregated for all items and services.

(B) The percentage of standard prior authorization requests that were denied, aggregated for all items and services.

(C) The percentage of standard prior authorization requests that were approved after appeal, aggregated for all items and services.

(D) The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services.

(E) The percentage of expedited prior authorization requests that were approved, aggregated for all items and services.

(F) The percentage of expedited prior authorization requests that were denied, aggregated for all items and services.

(G) The average and median time that elapsed between the submission of a request and a determination by the MA plan, for standard prior authorizations, aggregated for all items and services.

(H) The average and median time that elapsed between the submission of a request and a decision by the MA plan for expedited prior authorizations, aggregated for all items and services.

  • View the Health Equity Analysis report (PDF) – Coming Soon 10/15/2025

Need Help?
Call our Customer Service team at 1-888-361-7526 (TTY 711) from
8:00 a.m. to 8:00 p.m., seven days a week from October 1 – March 31,
& Monday – Friday, April 1 – September 30. The call is free.

7751 S. Manthey Road French Camp, CA 95231
1-888-361-7526 (TTY: 711)

Hours of Operation: 8:00 a.m. – 8:00 p.m.
Mon – Sun: October 1 – March 31
Mon – Fri: April 1 – September 30

 

Advantage D-SNP 2026 Benefits

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Posted on August 12th, 2025 and last modified on October 6th, 2025.

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