We Listen To What Our Members Say

Our grievance and appeals process gives our members a way to resolve concerns with the medical care and services we provide. We work closely with our members’ health plans and follow their rules for handling the issue. Whether the problem concerns access to care, dissatisfaction with our doctors or employees or a decision we made about medical services, we will investigate the issue and work toward a satisfactory solution.

If you have a problem that needs to be brought to our attention or disagree with a decision we made about a service request, you must first contact your health plan. You can file your complaint over the phone by calling the number printed on your health plan ID card. Please refer to your health plan member information materials for more detailed instructions on how to file a complaint/grievance or service denial appeal.

In addition to your health plan’s grievance and appeal process, you may also contact the California Department of Managed Health Care (DMHC). The DMHC regulates healthcare service plans. Before contacting the DMHC, you should first phone your health plan and use their grievance process. The DMHC has a toll-free telephone number (1-800-400-0815) to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service’s toll-free numbers (800) 735-2929 (TTY) or (888) 877-5378 (TTY) to contact the DMHC. The Department’s Internet web site (http://www.hmohelp.ca.gov) has complaint forms and instructions online.

The Differences Between Complaints, Grievances and Appeals

A complaint is defined as a member telephone call expressing concern about Valley Care Select IPA related issues by calling the Customer Service toll free at (877) 299-5599 or (805) 604-3332; hearing impaired (888) 877-5378.

A grievance is defined as a written member complaint expressing concern about Valley Care Select IPA related issues and is filed directly with your health plan as listed on the back of your identification card.
Learn more detailed information about complaints and grievances here.

An appeal is defined as a denial or limitation of a service, treatment, procedure or therapy in the utilization review process you believe is not correct. You have the right to appeal in writing to your health plan by submitting a copy of your denial notice and a brief explanation of your situation, or other relevant information to your health plan.
Learn more detailed information about the appeal process here.

 

Member Grievance Forms

Types of Complaints and Grievances

Complaints and grievances are classified as either quality of care or administrative in nature:

Type I: Quality of care complaints/grievances are defined as those which may affect the clinical adequacy, appropriateness and availability. These cases may include delayed and denied referrals, poor appointment access, and unsatisfactory care or service rendered. Quality of care issues are investigated and monitored by the QM Committee.

Type II: Administrative complaints/grievances are those that usually do not affect quality of care or service. They may include issues with Valley Care Select IPA or health plan procedures and processes. The QM Department delves into reported internal operations issues and monitors trends.

Appeals

Once you have sent in your appeal in writing to your health plan by submitting a copy of your denial notice and a brief explanation of your situation, your health plan will then document and process your standard or expedited appeal and provide you with written notification of the decision. You or an authorized representative may write, call or fax your appeal to your health plan. Health plan address, telephone and FAX number is listed on the back of your identification card. There are two types of appeals:

Standard Appeal Process
A standard appeal will be resolved within 30 days. Your health plan will notify you in writing of the decision within 30 calendar days of receiving your appeal.

Expedited/72-hour Appeal Process
Your health plan makes every effort to resolve your appeal as quickly as possible. In some cases, you have the right to an expedited appeal when a delay in the decision making might pose an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb, major bodily function, or if the normal timeframe for the decision-making process would be detrimental to your life, health or could jeopardize your ability to regain maximum function. If you request an expedited appeal, your health plan will evaluate your appeal and health condition to determine if your appeal qualifies as expedited. If so, your appeal will be resolved within 72 hours. If not, your appeal will be resolved within the standard 30 days.

If you need more information about your health plan or DMHC complaint/grievance or appeal process, call our Member Services Department at the number listed in the Call Us For Help section of the Member Handbook.