Imperial Health Plan of California Member Rights

How to contact us when you are making a complaint about your medical care

You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. Your health and satisfaction are important to us. When you have a problem or concern, please call us. We will work with you to try to find a satisfactory solution to your problem. Please see below for the phone numbers, addresses, and/or fax numbers for different types of problems and concerns. We pledge to honor your rights as a Medicare member, to take your problems and concerns seriously, and to treat you with fairness and respect. However, if for some reason an issue is not settled to your satisfaction, there are formal steps you can take.

You can refer to Chapter 9 What to do if you have a problem of complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage for more information about appeals and grievances. You can also learn more about coverage determinations and exceptions on the Centers for Medicaid and Medicare website https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminationsandExceptions.html

Concerns about Services – Organization Determinations

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. 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. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a certain medical service or if your healthcare provider refuses to provide medical care you think that you need. In other words, 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.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with any of our coverage decisions, you can make an appeal.

There are two types of formal process for handling problems and concerns about services, the Appeals Process, and the Grievance Process:

Appeals Process

You may request an Appeal when: A service was denied by the plan or delegated medical group and you believe you are entitled to receive the service. You or your representative must ask for an appeal in writing. If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR process below).

Examples of when you can file an appeal are:

  • You are not getting certain medical care you want and you believe the plan covers this care.
  • Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe the plan covers this care.
  • You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care.
  • You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
  • You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

There are two types of appeals you as a member have the rights to request, a Standard Appeal and an Expedited (Fast) Appeal

Standard Appeal

If you are asking for a standard appeal, you may file your appeal in any of the ways listed below. You must make your appeal request within 60 calendar days from the date of the written denial notice you received denying your service. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. The plan will provide a response to you no later than 30 calendar days from receipt date of your appeal.

Expedited/Fast Appeal

If your health requires it, you may ask for a “fast appeal” in any of the ways listed below. If we are using the fast deadlines, we must give you our decision within 72 hours after we receive your appeal request. We will give you our answer sooner if your health requires it. Your request for an expedited “fast” appeal must meet certain criteria set forth by Medicare. You may request an expedited “fast” appeal at any time, the plan will make the determination whether it meets the criteria or not. If it does not, your appeal will automatically be handled under the standard appeal process (above) and you will be notified immediately regarding the plans decision to process as a standard appeal. Upon this notification and should you disagree with our decision to not work you appeal fast, you will be given additional rights for an expedited grievance (complaint). The plan will always make every effort to resolve your appeal request as quickly as your health requires.

To begin your appeal, please contact us in any of the ways below. If you feel your health requires a fast response, please request an expedited “fast” appeal.

  • Phone: Call Member Services at 1-800-708-8273 TTY: 711.
  • Fax: Submitting a written appeal or a completed Imperial Health Plan Appeal Request Form by fax to 1-626-380-9049.
  • Email: appealsgrievances@www.imperialhealthplan.com with a completed Imperial Health Plan Appeal Request
  • Send a letter to us. Mail your written request to:

Imperial Health Plan of California, Inc.
Attn: Appeals & Grievances
PO Box 60874
Pasadena, CA 91116

You can download the Imperial Health Plan Appeal Request Form here: Appeal Form – [PDF, 265KB]

Upon receipt of your appeal, our plan will make every effort to determine whether the original decision to deny is correct. This process is called a Level 1 Appeal and includes reviewing all available information about your request and contacting your doctor or other treating providers to gather additional information, if needed. If the plan decides to approve the initially denied service you will be notified as quickly as possible, but no later than 72 hours for an expedited appeal and 30 calendar days for a standard appeal request. You will also receive a letter in the mail regarding our decision.

Should our medical director decide to not approve, continues to deny, the previously denied services, your appeal will automatically be forwarded to the Independent Review Organizations; also known as the Independent Review Entity (IRE). The IRE, Maximus Federal Services is an independent organization that is hired by Medicare (not the plan). If our plan denies your Level 1 Appeal, the IRE will review the plan’s decision. The IRE then decides whether the decision we made should be changed or stand as denied. This is called a Level 2 Appeal. You will receive written notification of their decision as quickly as your health requires, but no later than 30 days from the day the IRE receives your Level 2 Appeal.

Additional information regarding the appeals process can be found on the Medicare website at: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/PartCRecon.html.

Grievance Process

Standard Grievance

You can request a Grievance when: You have any type of complaint or dispute, expressing dissatisfaction with the way a Medicare Health Plan or delegated entity provides health care services. You or your representative may make a complaint/grievance either orally or in writing.

If you feel you have experienced a problem with your medical care or our services, you can request to file a formal complaint (grievance). Keep in mind, the complaint process is used only for certain types of problems including but not limited to quality of care, waiting times and customer service you receive.

Your complaint must be made within 60 days after the problem occurred that you want to complain about. Below are the two types of complaints we can process:

Expedited (Fast) Grievance

A fast complaint can be requested for the following reasons:

  • If we denied your request for a ‘fast coverage decision’ or a ‘fast appeal’, we will automatically give you the option to request a “fast complaint”.
  • If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a “fast complaint”.

If you have a “fast complaint” which meets the above criteria we will give you an answer within 24 hours.

Upon receipt of your standard grievance, the plan will acknowledge receipt of your complaint and provide you with a written response as quickly as your health requires, but no later than 30 calendar days from the date your complaint was received.

You may request both an expedited (fast) and a standard grievance through the following:

  • Phone: Call Member Services at 1-800-708-8273 TTY: 711.
  • Fax: Submitting a written grievance or a completed Imperial Health Plan Grievance Request Form by fax to 1-626-380-9049.
  • Email: appealsgrievances@www.imperialhealthplan.com with a completed Imperial Health Plan Grievance Request Form
  • Send a letter to us. Mail your written request to:

Imperial Health Plan of California, Inc.
Attn: Appeals & Grievances
PO Box 60874
Pasadena, CA 91116

You can download the Imperial Health Plan Grievance Request Form here: Grievance Form – [PDF, 243KB]

Important reminder: When your Grievance (complaint) is about quality of care, you also have additional options:

  1. You can make your complaint to the Quality Improvement Organization (QIO).

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). Livanta is California’s QIO and can be reached through the following:

  • Call: 1-877-588-1123 (TTY: 1-855-887-6668)
  • Write to:
    BFCC-QIO Program
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701
  1. Or if you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization, Livanta, following the same processes above.

You can also file a complaint about the plan by going directly to Medicare and calling 1-800-Medicare or going to https://www.Medicare.gov/MedicareComplaintForm/home.aspx

Additional information regarding the grievance process can be found on the Medicare website at: https://www.cms.gov/Medicare/Appeals-and-grievances/MMCAG/Grievances.html

Appointment of Representative Form

This form confirms your request for a person, other than yourself, to act as your representative in connection with an appeal of grievance (complaint) request and must be completed and received before the plan can process your request.

You can download the Appointment of Representative Form by clicking on your preferred language below.

Please complete your form and mail to:
Imperial Health Plan of California, Inc.
PO BOX 60874
Pasadena, CA 91116

You may also fax your form to:
1-626-380-9049

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.

If you would like information on how to obtain information about the total number of grievances, appeals, and exceptions filed with our plan, contact us for more information.

 


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