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For Medicare Members

What is an Grievance or Appeal?

Chinese Community Health Plan (CCHP) is committed to ensuring your satisfaction as a member of our Medicare Advantage Plans. If you encounter any issues, please reach out to our Member Services team . They can help explain your health plan benefits and assist in resolving problems. If necessary, they will guide you through the process of filing an appeal or grievance, and rest assured, CCHP does not discriminate against members who file such requests. For detailed instructions on filing an appeal or grievance, refer to Chapter 9 of your Evidence of Coverage (EOC). If you have questions about the number of grievances, appeals, or exceptions filed with CCHP, feel free to contact our Member Services.

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If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also file an appeal if you disagree with our decision to stop services that you are receiving.

For example, you can file an appeal:

  • If CCHP refuses to cover or pay for services or benefits you think should be covered;
  • If CCHP or one of the Plan providers refuses to give you a service you think should be covered;
  • If CCHP or one of the Plan providers reduces or cuts back on services or benefits you have been receiving; or
  • If you think CCHP is stopping your coverage of a service or benefit too soon.

A grievance is a type of complaint you make about CCHP or one of our network providers or pharmacies, including a complaint concerning the quality of your care or service. This type of complaint typically does not involve coverage of services or drugs or payment disputes.

For example, you would file a grievance if you have a problem with:

  • The quality of your care;
  • Waiting times for appointments or in the waiting room;
  • The way your doctors or others behave;
  • Being able to reach someone by phone or get the information you need; or
  • The cleanliness or condition of the doctor’s office.

To start an appeal, you, your doctor, or your representative can contact our Member Services. You must file an appeal in writing by submitting a signed request form or a written document to tell us what you are appealing and why you are filing an appeal. The appeal request form is available online and at the Member Services Center, however you are not required to use this form.

Your doctor or other provider can request a coverage decision appeal or reconsideration for you. An example of a coverage decision appeal would be when CCHP denies you coverage for services or durable medical equipment that you and your doctor think you need.

If you have someone appealing your decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. The Appointment of Representative form is available on the CCHP website and at the Member Services Center. While CCHP can accept an appeal request without the Appointment of Representative form, CCHP cannot complete our review until we receive it. If CCHP does not receive the Appointment of Representative form or other appropriate legal papers supporting an authorized representative’s status within 44 days after receiving your appeal request, your appeal request will be sent for dismissal.

You must file your appeal request within 60 calendar days from the date of the denial letter, informing you of the Plan’s decision to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, CCHP may be able to give you more time to file your appeal.

Please send your request to: CCHP Member Services Center, 445 Grant Avenue, San Francisco, CA 94108; or fax to 1-415-397-2129.

To start a grievance, you or your representative can contact our Member Services. 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.

The complaint must be made within 60 calendar days after you experienced the problem you want to complain about. CCHP must notify you of the decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. CCHP may extend the time frame by up to 14 calendar days if you request the extension, or if the Plan justifies a need for additional information and the delay is in your best interest.

Please send your request to: CCHP Member Services, 445 Grant Avenue, San Francisco, CA 94108; or fax to 1-415-397-2129.

What happens after you file an appeal or grievance?

Within 5 days after receiving your request, CCHP will send you a letter letting you know that your request or complaint has been received. Within 30 days of receiving your request was received, CCHP will send you a written notice with an answer or response to your complaint and the next steps in the process if you are not satisfied with the response. If you have any questions regarding the process or status, please contact our Member Services.

Complete Details

For more details about the appeal and grievance procedures, please review your Evidence of Coverage.

Expedited Review

You can ask for a fast appeal or grievance if you or your doctor believes that waiting too long for a decision could seriously harm your health. You may call, send or fax your request to Members Services. CCHP must respond on a fast appeal no later than 72 hours after the request is received. For a fast grievance, we must decide no later than 24 hours after the request is received whenever, 1. CCHP extends the time frame to make an organization determination or reconsideration, or 2. CCHP refuses to grant a request for an expedited organization determination or reconsideration.

H0571_2020_272_2020 Last Updated 10/11/2019

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