Grievances & Appeals

Do you have a Complaint or Grievance?

Your satisfaction is important to us! If you have a problem with the Alliance, you have the right to make a complaint. This is also called filing an appeal or a grievance. An appeal is when you ask for review of an “action.” Actions are:

  • A denial or limited authorization of a requested service
  • A reduction, suspension, or termination of a previously authorized service
  • A failure to provide services in a timely manner
  • A failure of the Alliance or the State to act within the time frames for grievances and appeals

A grievance is a complaint from you about any service you receive. For example, you got what you wanted, but didn't like it.

Tell Us About It!

If you have a problem with your health care services, please call our Member Services department. 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. If you have a grievance or appeal, you may file it by phone or fill out a form. Your provider may file an appeal for you. For help, please contact us.

If you have a problem, you must file a grievance with the Alliance within 180 calendar days of the event that caused your grievance. If you have Medi-Cal, you must file an appeal of an action within 90 calendar days of the date services or benefits were denied. If you have Alliance Group Care, you must file an appeal of an action within 180 calendar days of the date services or benefits were denied.

The Alliance will review your grievance or appeal and respond within 30 calendar days, or sooner, based on your health condition.

  • Call the Member Services department at 510-747-4567, Monday-Friday, 8 a.m. - 5 p.m.
  • CRS for hearing impaired at 711 or 1-800-735-2929
  • Outside of the 510 area code call us at 1-877-932-2738
  • Send us a fax at 1-855-891-7258
  • Write to us at:
    Alameda Alliance for Health
    G & A Unit
    1240 South Loop Road
    Alameda, CA 94502

Grievance Form

Do you have an Urgent Grievance or Appeal?

If you think that waiting 30 days will harm your health, be sure to say why when you file your grievance or appeal. You may then be able to get an answer within three (3) calendar days. In this case, you will have 24 hours to give us your views or any papers that support your views. The Alliance must give you a decision within 30 days or within three (3) days if your problem is an immediate and serious threat to your health.

Your Grievance and Appeal Rights

You will be treated with respect during the Alliance grievance or appeal process. You have the right to give the Alliance your views, or provide papers that support your views, or propose a solution. You may speak for yourself or have someone else speak for you, including a lawyer. Using this process does not rule out any potential legal rights or remedies that you may have.

You may ask to look at or get a copy of our records that relate to your case at no charge to you. You or your provider may get a copy of the benefit provision, guideline protocol, or criteria used to make a denial decision by calling our Member Services department.

Appeals

At the time you file your appeal, you can ask the Alliance to continue with the services until the grievance or appeal process is complete. The Alliance must give you a decision within 30 days or within three (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 appeal process before you apply for an Independent Medical Review (see below). You must ask for the IMR within six (6) months after the Alliance sends you a written response to your appeal.

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

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 ten (10) calendar days of the date on the letter that 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. However you participate, 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, 8:00 am - 5:00 pm, Monday through Friday

The California Department of Managed Health Care (DMHC)

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your plan, you should first telephone your plan at 1-877-932-2738 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-HMO-2219) and a TDD line (1-877-688-9891) for hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms, and instructions online.

Independent Medical Review (IMR)

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). In most cases, you must complete the Alliance’s appeals process before you apply for an IMR with DMHC. However, if the Alliance initially denied your treatment because it was experimental or investigational, you do not have to take part in the Alliance's appeal 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 appeal. If the IMR is decided in your favor, the Alliance must give you the service or treatment you asked for. 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) or visit their website at: http://ddtp.cpuc.ca.gov/default1.aspx?id=1482
  • You can find DMHC forms and more information online on the DMHC website 

If you qualify for an IMR, the HMO Help Center will review your application and send you a letter within seven (7) days telling you that you qualify for an IMR. After all your information is received, such as medical records, the IMR decision will be made within 30 days or within three (3) to seven (7) days if your case is urgent. Doctors will review your case and you will receive notice of the decision. If the IMR is decided in your favor, the Alliance must give you the service or treatment you asked for.

If you do not qualify for an IMR, your issue will be reviewed through the DMHC’s standard complaint process. You will receive a written notice of decision within 30 days. If you decide not to use the IMR process, you may be giving up your rights to pursue legal action against the Alliance about the service or treatment you are asking for.

DMHC 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.

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 (For Medi-Cal members only)

The Medi-Cal Managed Care Office of the Ombudsman can look into and solve problems. The Ombudsman can help members with urgent enrollment and dis-enrollment problems. The Ombudsman can also offer information and referrals. Call 1-888-452-8609 to reach the Ombudsman.

State Fair Hearings (For Medi-Cal members only)

If you are a Medi-Cal member, you may ask for a State Fair Hearing by filling out the 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).

You can file a grievance with your health plan and ask for a State Hearing at the same time. If you want a State Fair Hearing, you must ask for it within 90 days of the action you are complaining about, Or if you and your treating provider want to keep your treatment going that is being stopped or reduced, you must ask for a state hearing within 10 days of the grievance response letter you get from the Alliance. Please tell us that you want to keep getting your treatment during the hearing process and have your treatments paid for by the Alliance.

If you are writing a letter to ask for a State Fair Hearing, be sure to include your name, address, phone number, social security number, and the reason you want a State Fair 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, tell us 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 cause danger to 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 cause danger to 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. Expedited cases are decided within three (3) working days. Requests for an expedited hearing can be mailed or faxed to:

Expedited Hearing Unit
State Hearings Division
744P Street
MS 19-65
Sacramento, CA 95814
FAX: (916) 229-4267

If you have questions or would like to learn more about expedited state hearings, you may contact the Department of Health Care Services, Medi-Cal Managed Care Division, Office of the Ombudsman at 1-888-452-8609.

Legal Help: You may speak for yourself at the state hearing or have someone else speak for you, such as a family member, friend or lawyer. You may be able to get free legal help through Alameda County or a legal service agency. Call Bay Area Legal Aid at 1-800-551-5554 or go to www.baylegal.org.