How to Submit a Provider Grievance
Any provider who renders service to PHC California enrollees may file a grievance about any aspect of the plan’s operations and performance, or behavior of its members or staff within 365 calendar days from the date of the incident that precipitated the complaint. Note that grievances/disputes regarding claims are addressed in “How to Submit a Claim Dispute.”
Upon receipt of a grievance in writing or over the telephone, the plan sends written acknowledgement of the grievance within five (5) business days to the submitting provider. The plan resolves grievances within 30 calendar days from the date of receipt of the grievance and sends a resolution letter to the provider who submitted the grievance.
If a provider is dissatisfied with the plan’s resolution to his or her grievance, he or she may submit an appeal within 180 calendar days from receipt of the plan’s resolution letter. A provider may also file an appeal if PHC California fails to resolve his or her grievance with the 30-day time frame described above.
To submit an appeal, a provider should submit the following documentation to the plan. Appeal submissions must be in writing.
- Letter requesting appeal and/or review of the grievance resolution
- Copy of the Provider Grievance Form or letter used to submit the grievance to the plan, if the grievance was submitted in writing
- Copy of the documents submitted with the grievance if applicable
- Copy of the plan’s grievance resolution letter, if applicable
- Copy of any other correspondence between PHC California and the provider
Upon receipt of an appeal, the plan sends written acknowledgement of the appeal within 15 calendar days to the provider who submitted it. The plan sends a written report of its investigation and conclusions to the appeal within 45 business days of receipt of the appeal.