Grievance Process (also referred to as "Complaint")

What is a Grievance?

As a Blue Shield Promise Cal MediConnect plan Member, you have a right to file a complaint (grievance) if you have a problem with your medical care or our services. However, the complaint process is used for only certain types of problems. They include quality of care, waiting times and the customer service you receive.

Download Grievance Form Fill Online Form

How to file a Grievance, step-by-step.

  • Contact us Promptly

    • Call Blue Shield Promise Cal MediConnect Member Services at (855) 905-3825 (TTY: 711), 8:00 a.m. - 8:00 p.m. seven days a week.
    • Fax a letter to us describing your Grievance.
      FAX number: (323) 889-5049
    • Send a letter to us describing your Grievance. Mail to:

    • Blue Shield Promise Cal MediConnect plan
      Member Appeals and Grievances (Complaints) Department
      601 Potrero Grande Dr.
      Monterey Park, CA 91755
    • Download the Grievance form by clicking on this link: Grievance Form and Instructions
  • We will Acknowledge Receipt of Your Grievance

    • We will acknowledge receipt of your written grievance within five (5) days of receiving it. We will conduct a review of your issues. We may request your medical records as part of our review.
    • We will mail you a response to your complaint within thirty (30) days of receiving your complaint. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint. We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.
    • If you are making a complaint because we denied your request for a 'fast coverage decision' or a 'fast appeal', we will automatically give you a 'fast complaint'.
    • If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a "fast complaint".
    • For Expedited grievance requests or "fast complaint," we will respond within twenty four (24) hours. We will address your grievance as quickly as your case requires based on your health status.
  • We Review Your Complaint and Give You Our Answer

    • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call.
    • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
    • If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

    Medicare and the Cal MediConnect Ombuds Program can also help you with complaints:

    • You can also tell Medicare about your complaint. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx or please call (800) 633-4227. TTY/TDD users can call (877) 486-2048
    • The Cal MediConnect Ombuds Program also helps solve problems from a neutral standpoint to make sure that our members receive all the covered services that we are required to provide. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or plan. The phone number for the Cal MediConnect Ombuds Program is (855) 501-3077. The services are free.

When your complaint is about quality of care:

You can make your complaint to the Quality Improvement Organization (QIO). This can be done without or in addition to making the complaint to Blue Shield of California Promise Health Plan.

  • The QIO is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.
  • QIO Contact Information:

  • Livanta (California's Quality Improvement Organization)
    Call: (877) 588-1123
    TTY: (855) 887-6668
    Fax: (855) 694-2929 for appeals / (844) 420-6672 for all other reviews/issues
    Write:
    Livanta BFCC-QIO Program
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701

When your complaint is about disability access or about language assistance:

You can file a complaint with the Office of Civil Rights at the Department of Health and Human Services.

  1. If you have a complaint about disability access or about language assistance, Call the Department of Health and Human Services’ Office for Civil Rights at (800) 368-1019, TTY (800) 537-7697. You can also call your local Office for Civil Rights at (562) 908-8501.
  2. You may also have rights under the Americans with Disability Act and under under ADA Amendments Act of 2008 (P.L. 110-325). You can contact the Cal MediConnect Ombuds Program for assistance (refer to contact information above).

For further information on the Grievance Process, Please refer to your Evidence of Coverage.

Aggregate Numbers

  • How to obtain an aggreagate number of grievances, appeals and exceptions filed with Blue Shield Promise Cal MediConnect plan
    • To obtain an aggregate number of Blue Shield Promise Cal MediConnect Plan's grievances, appeals and exceptions, please call Blue Shield Promise Cal MediConnect Plan Member Services at (855) 905-3825, (TTY: 711), from 8:00am to 8:00 pm, seven days a week.

Extra Help

  • If you need further help, call the Cal MediConnect Ombudsman at (855) 501-3077. You can also call the HMO Help Center at (888) 466-2219. They can help you file a complaint or ask for an independent Medical Review.

You may ask to obtain the aggregate numbers of the plan's grievances, appeals, and exceptions. Please contact Member Services at (855) 905-3825 (TTY: 711), from 8:00am to 8:00 pm, seven days a week.


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