Filing a Grievance
If you are unhappy with PHC California for any reason, you can file a complaint (or grievance). You can file a grievance any time. You can’t be disenrolled or penalized if you file a grievance.
You can also file a grievance in writing. Explain in detail what happened to make you unhappy. Tell us the names and titles of the people involved, and the date, time and location of the incident. Include your name, PHC California ID number found on your ID card, current address, and phone number. You can use our complaint and grievance form, if you like. Send your grievance to Member Services. You can also fax it to us. Instructions are also on the complaint and grievance form.
Your doctor can file a grievance for you if you give him or her written approval.
We will send you a letter telling you we got your grievance. We’ll send the letter within five (5) business days from the day we got it. We must resolve your grievance within 30 calendar days from the day we got it. We will send you a letter that tells what we did to address your concerns.
If you call PHC California about a grievance that is not about health care coverage, medical necessity, or experimental or investigational treatment, and your grievance is resolved by the end of the next business day, you may not receive a letter.
You can ask for an “expedited or urgent” grievance 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” grievance 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” grievance, 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 grievance give you notice as quickly as your condition requires, but within 72 hours after PHC California receives your grievance;
- 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” grievance, the health plan will:
- Transfer your grievance to the standard timeframe. The standard timeframe is no longer than 30 calendar days from date when PHC California received your request for an expedited grievance.
- 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
You may also contact the Medi-Cal Managed Care Office of the Ombudsman at (888) 452-8609, Monday through Friday, 8:00 a.m. to 5:00 p.m. The Office of the Ombudsman helps solve problems from a neutral standpoint to ensure that Medi-Cal beneficiaries receive all medically necessary covered services for which health plans are contractually responsible.
If your grievance is still not resolved, or you are unhappy with the result, you can call 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 detail about the complaints process, look in the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2022). See Section 5, Reporting and Solving Problems.
DHCS 030716 PHC FR Form 1.0