California PHC

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.