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Filing a Grievance or Appeal

If you are unhappy with anything about your care or with Care1st, we want to know about it so we can help. We also want to hear your suggestions about how we can improve our services.

If you have a complaint, grievance or appeal you may:

  • Write, Visit, Call or Fax
    Care1st Health Plan Grievance Department at:
    601 Potrero Grande Dr.
    Monterey Park, CA 91755

    Phone: 1-800-605-2556
    Grievance Fax – 323 889-5049
    Appeal Fax – 323 889-5049
  • Fill out a grievance or appeal form available at your provider's office.
  • Fill out and submit an online grievance or appeal form that are available on this Website.
  • Write a letter to file a grievance or appeal.

Grievance Guidelines

You may file a grievance at any time. Care1st Health Plan will work with you to resolve your grievance. Standard grievances will be acknowledged within five (5) days and resolved within thirty (30) days. If however, your grievance involves an immediate and serious threat to your health, including but not limited to potential loss of life, limb, or major bodily function, your grievance will be resolved within 72 hours or sooner when necessary because of your medical condition. All grievance decisions can be appealed. An explanation of the appeal process will be outlined on the Grievance Resolution Letter that will be sent to you within thirty (30) days of filing the grievance.

Appeal Guidelines

If you think we have made a mistake in denying your medical service or you don’t agree with the decision, you can ask for an appeal. You must request an appeal within 60 calendar days from the date on the Notice of Action sent to you. You may call Care1st to file an appeal verbally. If you file verbally, you will be asked to submit a written, signed appeal, excluding expedited appeals.

Care1st Health Plan will work with you to resolve your appeal. Standard appeals will be acknowledged within five (5) days and resolved within thirty (30) days. If however, your appeal involves an immediate and serious threat to your health, including but not limited to potential loss of life, limb, or major bodily function, your appeal will be resolved within 72 hours or sooner when necessary because of your medical condition. You may appeal Care1st’s appeal decision. An explanation of the appeal process will be outlined on the Notice of Appeal Resolution (NAR) letter that will be sent to you within thirty (30) of filing the appeal.

The California Department of Managed Healthcare

"The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your Health Plan, you should first telephone your Health Plan at 1-800-605-2556 and use your Health Plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your Health Plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a Health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has toll-free telephone number 1-888-HMO-2219 and a TDD line 1-877-688-9891 for the hearing and speech impaired. The department's internet web site www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online."

Independent Review (IMR) of Grievances Involving a Disputed Health Care Service

IMPORTANT INFORMATION
You must exhaust Care1st's internal appeal process prior to proceeding to a State Hearing or IMR.

Effective January 1, 2001, patients may now request from the DMHC an independent Medical Review (IMR). Following is a copy of the IMR language and the IMR Request Form.

You may request an independent medical review (“IMR”) of disputed health care services from the Department of Managed Health Care ("DMHC") if you believe that health care services have been improperly denied, modified, or delayed by the Plan or one of its contracting providers. A “disputed health care service” is any health care service eligible for coverage and payment under your subscriber contract that has been denied, modified, or delayed by the Plan or one of its contracting providers, in whole or in part because the service is not medically necessary.

The IMR process is in addition to any other procedures or remedies that may be available to you. You pay no application or processing fees of any kind for IMR. You have the right to provide information in support of the request for IMR. The Plan must provide you with an IMR application form with any grievance disposition letter that denies, modifies, or delays health care services. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan regarding the disputed health care service.

Eligibility: Your application for IMR will be reviewed by the DMHC to confirm that:

(1)(A) Your provider has recommended a health care service as medically necessary, or (B) You have received urgent care or emergency services that a provider determined was medically necessary, or (C) You have been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which you seek independent review;

(2) The disputed health care service has been denied, modified, or delayed by the Plan or one of its contracting providers, based in whole or in part on a decision that the health care service is not medically necessary;

(3) You have filed a grievance with the plan or its contracting provider and the disputed decision is upheld or the grievance remains unresolved after 30 days. If your grievance requires expedited review you may bring it immediately to the Department’s attention. The DMHC may waive the requirement that you follow the Plan’s grievance process in extraordinary and compelling cases.

If your case is eligible for IMR, the dispute will be submitted to a medical specialist who will make an independent determination of whether or not the care is medically necessary. You will receive a copy of the assessment made in your case. If the IMR determines the service is medically necessary, the plan will provide the health care service.

For non-urgent cases, the IMR organization designated by the DMHC must provide its determination within 30 days of receipt of your application and supporting documents. For urgent cases involving imminent and serious threat to your health, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of your health, the IMR organization must provide its determination within 3 business days.

For more information regarding the IMR process, or to request an application form, please call the Plan's Member Services Department at (800)605-2556.

State Hearing

IMPORTANT INFORMATION
You must exhaust Care1st's internal appeal process prior to proceeding to a State Hearing or IMR.

If you want a State Hearing, you must ask for one within 120 days from the date on the "Notice of Appeal Resolution" (NAR) letter. But, if you are currently getting treatment and you want to continue getting treatment, you must ask for a State Hearing within 10 days from the date the NAR letter was postmarked or delivered to you, OR before the date your health plan says services will stop. You must say that you want to keep getting treatment when you ask for the State Hearing.

You can ask for a State Hearing by phone or in writing:

  • By phone: Call 1-800-952-5253. This number can be very busy. You may get a message to call back later. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349.
  • In writing: Fill out a State Hearing form or send a letter to:
    California Department of Social Services
    State Hearings Division
    P.O. Box 944243, Mail Station 9-17-37
    Sacramento, CA 94244-2430

    A State Hearing form is included with the NAR letter. Be sure to include your name, address, telephone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and telephone number to the form or letter. If you need an interpreter, tell us what language you speak. You will not have to pay for an interpreter. We will get you one.

After you ask for a State Hearing, it could take up to 90 days to decide your case and send you an answer. If you think waiting that long will hurt your health, you might be able to get an answer within 3 working days. Ask your doctor or health plan to write a letter for you. The letter must explain in detail how waiting for up to 90 days for your case to be decided will seriously harm your life, your health, or your ability to attain, maintain, or regain maximum function. Then, make sure you ask for an "expedited hearing" and provide the letter with your request for a hearing.

You may speak at the State Hearing yourself. Or, you can have a relative, friend, advocate, doctor, or attorney speak for you. If you want another person to speak for you, then you must tell the State Hearing office that the person is allowed to speak on your behalf. This person is called an "authorized representative".