PHC California

Rachel Sakai
AHF Provider

If You Have a Problem or Complaint

If you are ever unhappy with the service or care you get from PHC California, you should file a grievance (a complaint) with us.  We want you to be satisfied with the plan, our staff and our providers.  By filing a grievance, you bring the problem you experienced to our attention so we can take action.  You help us become a better health plan.

A “grievance” is an expression of dissatisfaction about any matter.  For example, you would file a grievance if you have a problem like:

  • The quality of your care
  • Waiting times for appointments
  • Waiting time to be seen while in a doctor’s office
  • The way your doctor or his or her staff behave
  • Unable to reach a provider or the managed care plan by phone
  • Inability to receive the information you need
  • Cleanliness or condition of a provider’s office.

An “adverse benefit determination” is the denial or limit by the plan of services asked for by you or your provider.  Examples of an action are:

  • Changing level of service, i.e., outpatient instead of inpatient hospital care
  • Reduction, suspension or termination of a service that was already authorized for you
  • Denial of all or part of the payment for a service or failure to provide the service in a timely manner
  • The health plan’s failure to act on a grievance you requested within 30 days of receiving your request.

An “appeal” is a request for a review of an adverse benefit determination.  For example:

  • If we won’t cover or pay for services you think we should cover, you can file an appeal
  • If we or one of our contracted providers won’t give you a service you think should be covered, you can file an appeal
  • If we or one of our contracted providers cuts back on services you have been getting, you can file an appeal
  • If you think we are stopping your coverage of a service too soon, you can file an appeal

With your permission, a provider can file a grievance or appeal for you.  The health plan is required to keep track of all grievances and appeal so it can report data to the State on a quarterly and annual basis. This information is also used to improve the plan’s service to its members.

Read how to file a grievance.  If you want to appeal an adverse benefit determination we made, read how to make an appeal. You can also read about how to ask for a State Hearing.

DHCS 030716 PHC Form 1.0