Problem Solving: Who to Call
Call your health plan.
If you have a problem with your services, try to talk to your doctor and your health plan. Your plan will have a procedure for you to follow to get more information or appeal a decision. If the problem is still not fixed, you have more options for help:
- Ombudsman Program: This special program can tell you about your options, including helping you file an appeal or grievance, or helping you set up a fair hearing. 1-855-501-3077
- Medi-Cal Managed Care Ombudsman: This existing program also can tell you about your options, including appeals, grievances and fair hearings. 1-888-452-8609
- 1-800-MEDICARE: You can contact this program with questions about your Medicare benefits. 1-800-633-4227
What if I want to change plans or programs?
You can always change health plans, or switch from Cal MediConnect to Medicare and a Medi-Cal managed care plan.
To make a change, call Health Care Options at 1-844-580-7272 or TTY 1-800-430-7077.
HOW TO…
File a Grievance
A grievance is a way of filing a simple complaint. If you have a concern with your services or with your Cal MediConnect plan, you can file a grievance. Your Cal MediConnect plan will work with you to resolve the problem.
Step 1: Contact your health plan.
- Plans must provide forms and a toll-free number through which you can file a grievance.
- Once you file, the plan must let you know they received it within five days.
- Most grievances are solved within 30 days.
File an Appeal
You can always if your Cal MediConnect plan denies, reduces, or ends services you think you should have. The health plan will take another look at your service needs and will send you a letter with a decision. If your appeal is about the plan stopping or reducing services that you already are receiving, you can keep getting the services in question while the appeal is considered by the plan— this is sometimes called “aid paid pending.”
You also have appeal rights if your plan does not cover drugs your doctor has prescribed. The pharmacist will provide you with information on how to ask for a coverage determination, which is the first step in drug appeals.
Step 1: You, your representative, or your provider must ask the health plan for an appeal within 90 days of getting a denial notice.
- Your written request must include: Your name, address, member number, reasons for appealing, any evidence you want the health plan to review, such as medical records, doctors’ letters, or other information that explains why you need the item or service.
- Call your doctor if you need this information. You can ask to see the medical records and other documents the health plan used to make their decision before or during the appeal.
- At no cost to you, you can also ask for a copy of the guidelines used to make the decision.
Step 2: Mail, fax, or deliver your appeal to the health plan, or call them.
- If you ask for a standard appeal by phone, they will repeat your request back to you to be sure they have documented it correctly. They will also send you a letter confirming what you told them. The letter will tell you how to make any corrections.
- Health plans often have a different phone number and fax for “Fast (Expedited) Appeals”. Check your health plan member handbook or call your health plan to ask for this information.
File a Medicare Appeal, Including for Prescription Drugs
For Medicare benefits, if your health plan has denied your appeal for services, you can request another appeal with the Medicare Independent Review Entity (IRE) through the health plan. For more help, you can also call 1-800-MEDICARE (1-800- 633-4227) or visit Medicare.gov.
Ask for a State Fair Hearing
For problems with Medi-Cal benefits that are denied, reduced, or stopped, such as long-term support services, you can ask for a Fair Hearing at any time. When you ask for a Fair Hearing, the Medi-Cal Program will listen to your case and make a decision. To ask for a Medi-Cal State Fair Hearing, you call 1-800-952-5253.
For Help with Grievances and Appeals
Making an appeal can be confusing and some deadlines are short. Your health plan must provide clear information on how to file a grievance and appeal. For help, you can also call at any time the Cal MediConnect Ombudsman at 1-855- 501-3077.