What is a grievance?
Grievance is also referred to as "complaint." As a Blue Shield of California Promise Health 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 only for certain types of problems. They include quality of care, waiting times, and customer service.
How to file a grievance
Step 1 – Contact us promptly
You may file a grievance in multiple ways: online, over the phone, or by faxing or mailing us a complaint letter or a completed Grievance form. Whether you call or write, be sure to contact us right away. The complaint must be made within 60 calendar days after you had the problem.
Download grievance form (PDF, 581 KB)
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." In legal terms a "fast complaint" is also called an "expedited grievance." If you have a "fast complaint," it means we will give you an answer within 24 hours.
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 also file a "fast complaint."
You may file a grievance by doing one of the following:
Call Blue Shield of California Member Services:
Phone:(800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week, from October 1 through March 31, and Monday through Friday, from April 1 through September 30.
Fax or mail your complaint letter to us:
Fax: (323) 889-5049
Send your complaint via mail:
Blue Shield of California Promise Health Plan
Member Appeals and Grievances (Complaints) Department
601 Potrero Grande Dr.
Monterey Park, CA 91755
Step 2 – We 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 an extension, or if we justify a need for additional information and the delay is in your best interest.
For Expedited grievance requests or "fast complaints," we will respond within twenty four (24) hours. We will address your grievance as quickly as your case requires based on your health status.
Step 3 – 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.
Step 4 – Make a complaint to the Quality Improvement Organization
When your complaint is about quality of care, you have one extra option. You can make your complaint to the Quality Improvement Organization (QIO). You can do this 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. Livanta is California's Quality Improvement Organization.
You can submit your complaint via phone, fax, or mail.
Phone: (877) 588-1123 [TTY: (855) 887-6668]
Fax: (833) 868-4063
Livanta BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
For further information on the Grievance Process, please refer to your Evidence of Coverage.
- Blue Shield Promise AdvantageOptimum Plan (HMO) and Coordinated Choice Plan (HMO) – refer to Chapter 9, Sections 1, 2, 3, and 10 of the Evidence of Coverage.
- Blue Shield Promise TotalDual Plan (HMO SNP) – refer to Chapter 9, Sections 1, 2, 3, 11 and 12 of the Evidence of Coverage.
You can also submit a complaint to Medicare
You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at (800) 544-0088 (TTY: 711), 8 a.m. – 8 p.m., seven days a week, from October 1 through March 31, and Monday through Friday, from April 1 through September 30.