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.
DHCS 030716 PHC FR Form 1.0