FILING A GRIEVANCE OR APPEAL
If you are unhappy with any aspect of your care or with Blue Shield of California Promise Health Plan, you may submit a complaint (grievance) at any time. We will resolve your concerns within 30 days of receiving your grievance.
If you think we have made a mistake in denying your medical service, or if you don’t agree with our decision, you can ask for an appeal. You must do this within 60 calendar days from the date on the Notice of Action sent to you. We will resolve your concerns within 30 days of receiving your complaint. However, if your appeal involves an immediate and serious threat to your health, we will respond to your appeal within 72 hours. This may include loss of life, limb, or major bodily function.
How to file a grievance or appeal
Blue Shield of California Promise Health Plan
3840 Kilroy Airport Way
Long Beach, CA 90806
Fax: (323) 889-5049
Fill out a grievance or an appeal form available at your healthcare provider’s office.
Download an appeal and grievance form in your preferred language. Note: These forms can be used for both grievances and appeals:
|Los Angeles County||San Diego County|
You may need to provide permission to release your medical records to your representative, or to support your case if you file a grievance, complaint, or appeal. If you find that you need to provide consent for this purpose, you may use the form below.
You may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as your representative to file an appeal or file a grievance on your behalf. Please use the form below to appoint a representative to act on your behalf.
I have filed an appeal or grievance, but I still have questions.
Since many members have the same questions as you do, we have made this list of Frequently Asked Questions. If you still have questions, call the Customer Care number on your member ID card.
I’m not clear on what my benefits are. How can I learn more?
Can someone file an appeal or a grievance for me?
You can choose to have someone file an appeal or grievance on your behalf. For example, this person could be a relative, friend, lawyer, or doctor. They can file appeals and grievances for you and ask for authorizations for you. If you want Blue Shield to speak or respond to the person filing on your behalf, you need to complete the . Both you and your representative must sign this form. Then return it to us at the address shown on the form. Without the Appointment of Representative form, we will not be able to provide any information to the person filing the case on your behalf.
How long does it take to review my appeal or grievance case?
The timing depends on your specific case. We want to do a thorough review. We may need to gather medical records, speak with your doctor, contact you, and/or consult with a specialist.
For a grievance: We will send you a letter letting you know that we received your notice of your concern within five calendar days. We will provide you with the name of the person who is working on it. We will normally resolve your case within 30 calendar days.
For a standard appeal: We will give you our answer on a request for a medical item or service within 30 calendar days for pre-service (services you have not received yet), or within 30 calendar days for post-service (for services you have already received) after we receive your appeal.
For an expedited (faster) appeal: As long as your request meets the requirements of an expedited appeal, we will give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health circumstances require us to do so.
What are the most common reasons for a denial?
The member may have used a service or requested an item that was not covered by their plan. The member may have had a treatment that was not deemed necessary or was not approved.
How do I get my appeal reviewed faster? Will calling help?
We can only do expedited (faster) reviews for appeals when there is an imminent and serious threat to the member’s health. This includes
- Severe pain
- Loss of major bodily function
- Potential loss of life
You may call to check on the case. We send you a letter within five days of receiving your appeal to let you know when we will respond to you with our decision. If you have added questions or wish to send more information to support your case, please call the number of the coordinator assigned to your case on the letter. You may also call the Customer Care number on your member ID card.
Can you email or call me instead of sending letters?
That depends on your specific situation. In some cases, the law requires us to send certain communications by mail. Whenever we can, we will honor your communication preferences.
What if my case is denied? What are my rights?
Each decision letter contains information on what your rights are and what steps you can take next, depending on your case.
I do not agree with Blue Shield Promise’s decision on my appeal or grievance. What can I do?
If you received a letter from us telling you that we did not change our decision, or if you never received a decision letter and it has been more than 30 days, you can:
- Ask for an Independent Medical Review (IMR) from the Department of Managed Health Care (DMHC). The DMHC is responsible for regulating healthcare plans. An outside reviewer – someone who is not part of Blue Shield Promise – will provide an impartial review of your case.
- Ask for a State Hearing from the California Department of Social Services (DSS). A judge will review your case.
California Department of Social Services State Hearing
DMHC Help Center phone: (TTY: ).
State Hearing request procedures
I have an appeal or a grievance concerning a medical emergency. What should I do?
If you need help with an appeal or a grievance involving an emergency, you may call DMHC for assistance at . Calling DMHC does not prohibit any potential legal rights or remedies that may be available to you.
Note that in non-emergency situations, you must first file your appeal or grievance with Blue Shield Promise prior to contacting DMHC for an Independent Medical Review. For Los Angeles, call (TTY: 711). For San Diego, call (TTY: 711).
I see a list of groups in my appeals letter. Who are they and what do they do?
We work with many groups that oversee health care. Many of them have rules to be sure that the appeals process is fair. Visit the websites listed on your appeals letter to learn more about them.
How can I withdraw my appeal or grievance request?
The person who filed your request (you or your representative) can call the coordinator assigned to your case and let them know. Or, you or your representative can let Customer Care know, and they will tell your case coordinator. To reach Customer Care, call the number on your member ID card.
Submit a grievance or an appeal online
File a complaint, grievance, or an appeal.
Frequently asked questions
See questions our members ask most frequently about Blue Shield Promise Medi-Cal.
Member rights and responsibilities
Find out about your rights and responsibilities as a Blue Shield Promise Medi-Cal member.
Get the Member Handbook (Evidence of Coverage) and other important documents for your area.