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 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.
