Grievances & Appeals – Health Plan of San Joaquin is committed to promoting and maintaining quality of care for our members. In order to do so we investigate all concerns of dissatisfaction with medical care or the delivery of care reported by you, our members.
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 at 1-209-942-6320 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 a health plan related to the 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet website http://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.
Medi-Cal members have the right to request a State Fair Hearing at any time during the grievance and appeal process. You may call the Department of Social Services toll-free at 1-800-952-5253 to request a State Fair Hearing. This type of hearing is an administrative proceeding where you can file your complaint directly with the State of California. If you decide to request a fair hearing, you may represent yourself at the hearing or someone else, such as a lawyer, friend, family member, or anyone you choose may represent you. The Department of Social Services can help you get a public defender, free of charge, to help you with your State Fair Hearing.
The best way to take care of a problem is to talk to your doctor. If you are not happy with the health services you received, you can file a complaint or “grievance.” It is your right to file a complaint or grievance. You will not be discriminated against or lose your benefits.
A complaint (grievance) is any form of dissatisfaction expressed by a member. It is important that you report any complaint to us filed at any time from the day the incident or action occurred. We will attempt to speak with all parties involved with your complaint in order to determine a cause and the best solution to ensure that the event is not repeated. We will inform you of the results of our investigation to ensure that you are as satisfied as possible with the recommendations.
An appeal is a formal request by you or your treating doctor to reconsider a decision to deny, delay or modify an authorization request submitted on your behalf. A Notice of Action (NOA) letter is a formal letter sent telling you that a medical service has been delayed, modified or denied and what you, your doctor or anyone that you appoint, may do in order to have the decision reconsidered. You must file an appeal with HPSJ within sixty (60) days from the date on the NOA letter that you receive. Appeals filed by the provider on behalf of the beneficiary require written consent from the beneficiary.
Any services previously authorized will continue while the appeal is being resolved. This notice does not affect any of your Medi-cal services.
How to Fax or Mail
If you need to file a complaint or appeal, you may contact us via phone, FAX, or by mail. Please download the PDF forms by clicking on any of the buttons below.
If you need send any of these forms to HPSJ via mail, please send them to the following address, please make sure mark it “Att: Appeals Department”.
Mail to: Health Plan of San Joaquin
Att: Appeals Department
7751 South Manthey Road
French Camp, CA 95231-9802