Do you have a Complaint or Grievance?
A grievance is a complaint from you about any service you receive. For example, you didn't get what you wanted. Or, you may submit a complaint when you got what you wanted, but didn't like it.



Tell Us About It!
  • Call Member Services between 8 a.m. - 5 p.m. at (510) 747-4567.
  • For TTD/TTY (510) 747-4501.
  • Outside of the 510 area code call us at (877) 932-2738.
  • Write to us at Alameda Alliance for Health, 1240 South Loop Road, Alameda CA 94502.
  • Fax to us at (510) 747- 4522.
Grievance Form

Your satisfaction is important to us! Tell us about your grievance. The Member Services department will ask you about the problem and start solving it. In some cases, we will be able to solve it right away. In other cases, we may need more information before finding a solution. You have 180 days from the time of the incident that caused your dissatisfaction to file a complaint, with the exception of an appeal (see below).

When this happens, we will send you a letter within 5 calendar days of receiving your grievance. The letter will tell you the status of your grievance and the name of a person you can contact if you have any questions. A Grievance and Appeal Coordinator will contact you by letter with a solution to your problem in 30 calendar days or less. If you think that waiting 30 days will harm your health, be sure to say why when you file your grievance.

Do you have an Urgent Complaint (Grievance)?
You may then be able to get an answer within 3 calendar days. Any grievance involving an imminent and serious threat to a member's health will be addressed by the Alliance within 3 calendar days of receiving the grievance. These cases include, but are not limited to: severe pain and/or potential loss of life, limb, or major bodily function. You may also contact the Department of Managed Health Care right away and tell them about this kind of grievance.

Appeal Process for Medi-Cal Members
You may have received a 'Notice of Action' from Alameda Alliance. Medi-Cal Members have 90 days from the date on the 'Notice of Action' to file an appeal with Alameda Alliance.

Appeal Process for IHSS Members only
A complaint by IHSS members when they did not get what they want is called an appeal. The complaint must be submitted in writing through a letter explaining why you disagree with the decision made by the Alliance. Also, be sure to provide information that supports your reason for appealing. Your appeal letter must be submitted within 10 calendar days of the date on the letter which states a decision was made to deny authorization or payment for medical services.

You may participate in a hearing for your appeal either in person, by telephone or in writing. The Alliance will inform you of the final decision by phone and in writing within 48 hours of the hearing's conclusion. Again, we will work to resolve your grievance and appeal within 30 days.

Additional Options for Members with a Complaint
  • Contact the California Department of Managed Health Care (DMHC) (see below)
  • Apply for an Independent Medical Review (IMR) (see below)
  • Medi-Cal members may contact the Managed Care Ombudsman or request a state hearing (see below)
  • If you suspect fraud you may wish to file a complaint with the State Fraud Hotline at Department of Health Care Services (DHCS) at 1-800-822-6222. This hotline has a recorded message that may be heard in English and four other languages: Spanish, Vietnamese, Cambodian, and Russian. The call is free and the caller may remain anonymous.
  • If you suspect fraud or elder abuse contact the California Bureau of Medi-Cal Fraud & Elder Abuse at 1-800-722-0432 or at: http://ag.ca.gov/bmfea/reporting.php
  • Call our Member Services department at any time if you need somebody to explain any part of the complaint or grievance process. Call 510-747-4567, 8 a.m. to 5 p.m., Monday through Friday.

Your Rights
You will be treated with respect during the Alliance grievance process. You have the right to give the Alliance your views or propose a solution. You may speak for yourself or have someone else speak for you. You may ask to look at our records in connection with your grievance.

The California Department of Managed Health Care
The Department of Managed Health Care is in charge of making sure all managed care health plans do what the law says they should do. You may call DMHC with any complaints you have about the Alliance.

If you have a grievance against the Alliance, you should first telephone us at 510-747-4567 and use our grievance process before contacting the DMHC. 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 the Alliance, or a grievance that has remained unresolved for more than 30 days, you may call DMHC for assistance.
  • DMHC toll-free number - 1-888-HMO-2219
  • TDD line (1-877-688-9891) for the hearing and speech impaired.
  • DMHC's Internet web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online

Independent Medical Review
An Independent Medical Review (IMR) is a review of your case by doctors who are not part of the Alliance. You can ask for an IMR from the HMO Help Center at the Department of Managed Health Care (DMHC). If the IMR is decided in your favor, the Alliance must give you the service or treatment you requested. This process is free of charge.

You Can Apply for an IMR if the Alliance:
  • Denies, changes, or delays a service or treatment because it has been determined as not medically necessary.
  • Will not cover an experimental or investigational treatment for a serious medical condition.
  • Will not pay for emergency or urgent medical services that you have already received.
To ask for an IMR:
  • Contact the HMO Help Center at 1-888-466-2219
  • TDD call 1-877-688-9891 (TDD), or the California Relay Service at 1-800-735-2929 (TDD) and www.IP-relay.com.

In most cases, you must complete the Alliance's grievance process before you apply for an IMR with the DMHC. The Alliance must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health. If the Alliance denied your treatment because it was experimental or investigational, you do not have to take part in the Alliance's grievance process before you apply for an IMR. You must ask for the IMR within 6 months after the Alliance sends you a written response to your grievance.

The DMHC also has an Internet website with forms and instructions at http://www.hmohelp.ca.gov. If you qualify for an IMR, the HMO Help Center will review your application and send you a letter within 7 days telling you that you qualify for an IMR. When all your information is received, including relevant medical records, the IMR decision will be made within 30 days or within 3 to 7 days if your case is urgent. You will be notified of the decision made by the doctors who have reviewed your case. If the IMR is decided in your favor, AAH must give you the service or treatment you requested.

If you do not qualify for an IMR, your issue will be reviewed through the department's standard complaint process. You will receive a written notice of their decision within 30 days. Please be aware that if you decide not to participate in the IMR process, you may be giving up your statutory rights to pursue legal action against the Alliance regarding the service or treatment you are requesting.

Additional Options for Medi-Cal Members
In addition to the using the Alliance process or one of the DMHC options listed above, Medi-Cal members have other methods for having their complaints resolved.

Medi-Cal Managed Care Ombudsman
If you feel the Alliance has not solved your problem, you may call this State office at 1-888-452-8609. Their office hours are from 8:00 a.m. - 5:00 p.m. They offer help to Medi-Cal members in managed care plans.

State Hearings
If you are a Medi-Cal member, you may ask for a state hearing by filling out a Form to File A State Hearing or by sending a letter to: California Department of Social Services, State Hearing Division, P.O. Box 944243, MS 19-37, Sacramento, CA 94244-2430. Or, you may call 1-800-952-5253 and request a state hearing form be sent to you. This number can be very busy, so you may get a message to call back later. If you have trouble hearing or speaking, call 1-800-952-8349 (TDD).

If you want a state hearing, you must ask for it within 90 days of the action you are complaining about, unless you and your treating provider want to keep your treatment going that is being stopped or reduced. Then, you must ask for a state hearing within 10 days of grievance response letter you will receive from the Alliance. Please state that you want to keep getting your treatment during the hearing process.

If you are writing a letter to ask for a state hearing, be sure to include your name, address, phone number, social security number, and the reason you want a state hearing. If someone is helping you ask for a state hearing, add their name, address and phone number to the letter. If you need a free interpreter, indicate what language you speak.

After you ask for a hearing, it could take up to 90 days for your case to be decided and for an answer to be sent to you. If you believe waiting that long will seriously put at risk your life or health or ability to attain, maintain, or regain maximum function, ask your doctor for a letter. The letter must explain how waiting for up to 90 days for your case to be decided will seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function. Then ask for an expedited hearing and provide the letter with your request for a hearing.

Legal Help: You may speak for yourself at the state hearing or have someone else speak for you, including a relative, friend or attorney. You must get the other person yourself. You may be able to get free legal help through Alameda County or legal services organizations. Check under "Legal Services" in the yellow pages.