The formal name for “making a complaint” is “filing a grievance.” A grievance is the kinds of problems related to:
- Quality of your medical care
- Respecting your privacy
- Disrespect, poor customer service, or other negative behaviors
- Physical accessibility
- Waiting times
- Information you get from our plan
- Language access
- Communication from us
- Timeliness of our actions related to coverage decisions or appeals
How to file a Grievance with IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
1. Contact us promptly – call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. You must file a grievance within 60 days of the event or incident, but there are some exceptions.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
- You can use our "Member Appeal and Grievance Form." All of our Doctor’s offices and service providers have the form or we can mail one to you. You can file a grievance online. You can give a completed form to our Plan provider or send it to us at the address listed below. This form is for IEHP DualChoice as well as other IEHP programs.
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
- We will send you a letter within 5 days, letting you know we received your grievance. We will work to resolve the complaint and we may contact you or your Provider for more information.
- The entire process will be resolved within 30 days. We will send you a letter explaining our decision within this time.
- The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.
- You can request a fast, (urgent) or (fast) grievance if you disagree with: (a) our decision not to expedite your request for an organization determination, redetermination, reconsideration, or coverage determination; (b) our decision to extend the timeframe for an appeal or organization determination. We will respond to your urgent grievance within 24 hours from the time that we received your request.
- Since some of your benefits are covered by Medi-Cal, you may also file a grievance with Medi-Cal. For help with your grievance or to complain about your health plan, you can call the Cal MediConnect Ombuds Program. The Cal MediConnect Ombuds Program can answer your questions and help you understand what to do to handle your problem. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan. They can help you understand which process to use. The phone number for the Cal MediConnect Ombuds Program is 1-855-501-3077. This number will be available after April 1, 2014. The services are free.
Whether you call or write, you should contact IEHP DualChoice Member Services right away. The grievance must be submitted within 60 days of the event or incident.
2. We will look into your complaint and give you our answer
- If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
- Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
- If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
If you are making a complaint because we denied your request for a “fast coverage determination” or fast appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
Who may file a grievance?
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call IEHP DualChoice Member Services.
When your complaint is about quality of care
You have two extra options:
- You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). To find the name, address, and phone number of the Quality Improvement Organization in your state, look in Chapter 2 of your IEHP DualChoice Member Handbook. If you make a complaint to this organization, we will work with them to resolve your complaint.
- Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization.
For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook.
Handling problems about your Medi-Cal benefits
If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), TTY at 1-800-718-4347, 8am - 8pm (PST), 7 days a week, including holidays.
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Information on this page is current as of September 29, 2017