申訴和上訴 – 聖華金健康計劃致力於促進和維護我們會員的護理質量。 為此,我們會調查您(我們的會員)報告的對醫療護理或提供護理服務的所有不滿。

來自管理式醫療保健部 (DMHC) 的消息
dmhc_logo
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 www.dmhc.ca.gov在線提供投訴表、IMR 申請表和說明。
A Message from the Department of Health Services (DHS)

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.

解決問題的最佳方法是與您的醫生交談。 如果您對所獲得的健康服務不滿意,您可以提出投訴或“申訴”。 您有權提出投訴或申訴。 您不會受到歧視或失去您的福利。

投訴(申訴)是會員表達的任何形式的不滿。 重要的是你report any complaint to us 隨時提交 從事件或行動發生之日起。 我們將嘗試與涉及您投訴的所有各方進行溝通,以確定原因和最佳解決方案,以確保事件不再發生。 我們會將調查結果通知您,以確保您對建議盡可能滿意。

上訴是您或您的主治醫生提出的正式請求,要求重新考慮拒絕、延遲或修改代表您提交的授權請求的決定。 行動通知 (NOA) 信函是一封正式信函,告知您醫療服務已被延遲、修改或拒絕,以及您、您的醫生或您指定的任何人為了重新考慮該決定而可能採取的措施。 您必須在收到 NOA 信函之日起六十 (60) 天內向 HPSJ 提出上訴。提供者代表受益人提出的上訴需要獲得受益人的書面同意。

在解決上訴期間,之前授權的任何服務都將繼續。 本通知不會影響您的任何 Medi-cal 服務。

立即在線提交

我們的 顧客服務部門1-888-936-計劃(7526) 可幫助您提出投訴或上訴,可以以書面陳述或完整表格的形式提交。

如何傳真或郵寄

如果您需要提出投訴或上訴,您可以通過電話、傳真或郵件與我們聯繫。 請單擊下面的任何按鈕下載 PDF 表格。

如果您需要通過郵件將這些表格中的任何一個發送到HPSJ,請將它們發送到以下地址,請務必標記“Attn: Appeals Department”.

郵寄至:Health Plan of San Joaquin
Attn: Appeals Department
南曼西路 7751 號
法國營地,CA 95231-9802

Posted on June 16th, 2015 and last modified on February 26th, 2024.

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