Grievance and Appeals Procedures

Grievance and Appeals Procedures

Grievance and Appeals

Grievance and Appeals

For CCHP Senior Program (HMO) and Senior Select Program (HMO SNP) Members

Chinese Community Health Plan (CCHP) wants you to be satisfied with the services you receive as a member of CCHP’s Medicare plan. CCHP wants to hear from you when you have any problems or issues with CCHP Senior Program (HMO) or CCHP Senior Select Program (HMO SNP). When you have a problem or a complaint, call our Member Services Center at 1-888-775-7888 from 8:00 a.m. to 8:00 p.m., seven days a week (TTY users should call 1-877-681-8898). Our Member Services staff can explain your health plan benefits, or, if your problem is about another matter, they will try to solve it right away. If our Member Services staff cannot solve your problem, they will help you file an appeal or grievance. CCHP will not discriminate against you because you file an appeal or grievance. For detailed instructions on how to file an appeal or grievance, please refer to Chapter 9 of your Evidence of Coverage (EOC). If you would like to obtain an aggregate number of grievances, appeals, and exceptions that have been filed with CCHP, please contact our Member Services Center.

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Drug Benefit Appeals and Grievances

There are separate procedures for filing an appeal or grievance that involves your Medicare Part D drug benefits. Please select the following for details:

What is a Coverage Decision

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. If you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.


How to ask for an Organization Determination

When a coverage decision involves your medical care, it is called an “organization determination."

To request an organization determination, you, your doctor or your representative can call our Member Services Center. If you do not wish to call, you, your doctor, or your representative may write or fax our plan to make your request.

Write:
Chinese Community Health Plan
Attn: Utilization Management
445 Grant Avenue, Suite 700
San Francisco, CA 94108
 
Call:
Toll-free Number: 1-888-775-7888
TTY: 1-877-681-8898
Seven days a week from 8:00 a.m. to 8:00 p.m.
Fax: 415-397-2129

What is an Appeal or Grievance

What Is An Appeal

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.

What Is A Grievance

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.

How to File an Appeal

To start an appeal, you, your doctor, or your representative can call our Member Services Center or submit a written request. You may 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 (PDF) 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 begin or 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 dismissed.

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:

Chinese Community Health Plan
Member Services Center
445 Grant Avenue, Suite 700
San Francisco, CA 94108

How to File A Grievance

To start a grievance, you or your representative can call our Member Services Center .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 of the event or incident 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.

Write:
Chinese Community Health Plan
Member Services Center
445 Grant Avenue, Suite 700
San Francisco, CA 94108
 
Call:
Toll-free Number: 1-888-775-7888
TTY: 1-877-681-8898
Seven days a week from 8:00 a.m. to 8:00 p.m.

Fax: 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 Center.

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.

Medicare Complaint Form

If you have any feedback or concerns about your Medicare plan, you may submit them directly to Medicare using the form below.

Complete Details

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

H0571_2020_272_2020 Last Updated 12/13/2019