Making an Appeal
You can appeal an action by PHC California within 60 calendar days of receipt of the health plan’s notice to you about our action (Notice of Action). Our notice to you will explain why the decision was made and include clinical guidelines or medical policies we used to make the decision.
Under California Health & Safety Code, Section 1363.5, when you receive a Notice of Action from us, it will contain this notice: “The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.”
You can file an appeal orally or in writing. To file your appeal orally, call Member Services. To file your appeal in writing, explain the action and provide detailed information and back-up documentation to support your appeal, and your desired outcome of the appeal. Include your name, your PHC California ID number, and current address and telephone number. Send your appeal to Member Services. If you need help with your written appeal or have questions, call Member Services.
The health plan’s timeframe to resolve your appeal begins on the date that we receive your oral request. A provider may file an appeal on your behalf, with your written consent. PHC California will resolve your appeal within 30 calendar days from the date the health plan received your initial request, unless you have requested an “expedited” process. The health plan is required to complete the expedited process within 72 hours. We may extend the timeframe to resolve your appeal by up to 14 calendar days if we need more time to get additional information and believe the delay is in your interest. If we extend the timeframe, we will attempt to contact you over the phone and send written notice to you about the extension within two (2) calendar days of our decision to extend the timeframe.
You can ask for an “expedited” or fast appeal if the time it takes for a standard resolution could seriously jeopardize your life, health or ability to attain, maintain or regain maximum function.
You can file an “expedited” appeal orally or in writing. You doctor may file one on your behalf, with your written consent. You do not need to follow-up this request in writing.
If you file an “expedited” appeal, PHC California will:
- Inform you of the limited time available to present your evidence and allegation of fact or law, in person or in writing;
- Resolve each expedited appeal and give you notice as quickly as your condition requires, but within 72 hours after PHC California receives your appeal;
- Provide you with a written notice of the decision; and
- Try to provide you with oral notice of the decision
If PHC California denies your request for an “expedited” appeal, the health plan will:
- Transfer your appeal to the standard timeframe. The standard timeframe is no longer than 45 calendar days from date when PHC California received your request for an expedited appeal.
- Try to call you to notify you of the denial of your request; and
- Provide you with written notice of the denial within two (2) calendar days
If the decision to your appeal is in your favor, PHC California will provide or authorize the services within 72 hours.
If the decision to your appeal is not in your favor, our written response back to you will include instructions and an application to request a State Hearing.
Continuation of Benefits
Your benefits will continue while your appeal is pending, if:
- You file your request for continuation or reinstatement of benefits in a timely manner on or before the later of: a) Ten (10) days from the date of PHC California’s notice of action to you (or 15 days, if the notice is sent via US mail), or b) prior to the intended effective date of our proposed action;
- The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
- The services must have been ordered by an authorized provider;
- The authorization period has not expired; and/or
- You request an extension of benefits.
PHC California will continue your benefits during this time until one (1) of the following occurs:
- You withdraw your request for the appeal
- Ten (10) calendar days pass from an oral request or 15 calendar days pass from a written (mailed) request from the date of the plan’s adverse decision and you have not requested a State Hearing with continuation of benefits
- An adverse decision is made (decision not made in your favor)
- The authorization expires or authorized service limits are met
If the final resolution of the appeal is in your favor, PHC California will pay for the disputed services as required. If the final resolution of the appeal is not in your favor, you may be liable for all costs accrued while your appeal was pending. PHC California may recover the cost of the services furnished while the appeal was pending.
What to Do if You Do Not Agree with an Appeal Decision
If you filed an appeal and received a letter from PHC California telling you that we did not change our decision, or you never received a letter telling you of our decision and it has been past 30 days, you can:
- Ask for a State Hearing from Department of Social Services, and a judge will review your case.
- Ask for an Independent Medical Review (IMR) from DMHC and an outside reviewer who is not part of PHC California will review your case.
You will not have to pay for a State Hearing or an IMR. You are entitled to both a State Hearing and an IMR. But if you ask for a State Hearing first, and the hearing has already happened, you cannot ask for an IMR. In this case, the State Hearing has the final say.
If your appeal is not resolved, or you are unhappy with the result, you can contact the California Department of Managed Health Care (DMHC) at 1-888-HMO-2219 (TTY 1-877-688-9891). (By clicking on the link above, you will be taken to a website operated by DMHC and not PHC California.)
For more information about the appeals process, see Section 5, Reporting and Solving Problems, in the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2023).
More Information About Health Plan Decisions
Our decisions about your health care are guided by Federal and State laws, including:
- Code of Federal Regulations, Title 42, Section 438.915
- California Health & Safety Code, Sections 1363.5 and 1367.01
- California Code of Regulations, Title 28, Section 1300.70(b)(2)(H) and (c)
We must give you or your health care provider information about how we make our decisions any time you ask. For more information, please see Section 3, How to Get Care, in the Member Handbook or call Member Services.
DHCS 030716 PHC FR Form 1.0