Grievance And Appeals - MemorialCare Select IPA Members

How to File a Grievance

MemorialCare Select Health Plan has a formal process for reviewing member grievances and appeals. This process provides a uniform and equitable treatment of your grievance/appeal and a prompt response. MemorialCare Select Health Plan shall ensure that all enrollees have access to and can fully participate in the grievance system by providing assistance for those with limited English proficiency or with visual or other communicative impairment. Such assistance shall include, but is not be limited to, translation of grievance procedures, forms and plan responses to grievances, as well as access to interpreters, telephone relay systems and other devices that aid disabled individuals to communicate. 

A grievance is a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration, or appeal made by a member or the member’s representative. When the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance. Members have up to 180 calendar days from the date of an incident or dispute, or from the date the member receives a denial letter, to submit a grievance or appeal to MemorialCare Select Health Plan.  

You may file a grievance in one of the following ways:

1. Telephone - Call the Member Services phone number on your MemorialCare Select Health Plan ID card or 1 (844) 805-8700.
2. Online - Submit your grievance online by logging into MyChart and filling out the GRIEVANCE FORM. Please attach any available documents. You can also fill out the GRIEVANCE FORM here.
3. Mail - Download the GRIEVANCE FORM below or on MyChart and mail the completed form with any attachments. Please, write neatly.

English: GRIEVANCE FORM

Spanish: GRIEVANCE FORM

Mail to:

Information you provide us becomes part of the permanent grievance record. You will be sent an acknowledgement within 5 calendar days and a response within 30 calendar days of us receiving this form or your call.

Independent Medical Review

MemorialCare Select Health Plan is responsible for the correspondence, resolution and forwarding your case to Independent Medical Review if needed.

You Can Apply for an IMR if your Health Plan:

• Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary
• Will not cover an experimental or investigational treatment for a serious medical condition
• Will not pay for emergency or urgent medical services that you have already received

Click below to download an Independent Medical Review form.

English: Independent Medical Review Form

Spanish: Formulario de revisión médica independiente

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-844-805-8700) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.

Appeals

Further Appeal Rights

If you are dissatisfied with your Primary Health Plan’s answer, you may be able to pursue one or more of the following appeal processes, depending on your situation and the appeal information contained in your Primary Health Plan’s Evidence of Coverage. If you need assistance please contact Member Services at the number on the back of your Primary Health Plan’s member ID card.

1. File a complaint with the Department of Managed Health Care (DMHC) provided that your health coverage is governed by them. Click on the following link to be directed to the DMHC web site http://www.dmhc.ca.gov/. If your health coverage is not governed by the DMHC, it may be governed by the Department of Insurance. Please contact your Primary Health Plan’s Member Services if you are not sure which entity governs your health coverage. Your Primary Health Plan’s Member Services number is on the back of your Primary Health Plan’s member ID card.
2. Request Independent Medical Review. Independent Medical Review is available for decisions to deny payment on the basis that the services are not medically necessary or that they are considered investigational or experimental. If your grievance involves a denial of health care service, information on the Independent Medical Review process will be provided in the letters sent to you by your Primary Health Plan.
3. Have your case reviewed in an administrative hearing if you are a Medicare beneficiary or a MediCal member. Those rights are identified in your Primary Health Plan’s Evidence of Coverage.
4. Seek legal remedies in a court of law.