Appeals and Grievance Procedures

For CCHP Senior Program (HMO) Members

Chinese Community Health Plan (CCHP) wants you to be satisfied with the services you receive as a member of CCHP. CCHP wants to hear from you when you have any problems or issues with the health plan. When you have a problem or a complaint, call Member Services at 415-834-2118 or 888-775-7888 from 8:00 a.m. to 8:00 p.m., seven days a week (TTY/TDD users should call 877-681-8898). Member Services can explain your health plan benefits, or, if your problem is about another matter, they will try to solve it right away. If Member Services cannot solve your problem, they will help you file an appeal or grievance. CCHP will not discriminate against you because you file an appeal or grievance. For detailed instructions on how to file an appeal or grievance, please refer to Chapter 9 of your Evidence of Coverage (EOC).

Drug Benefit Appeals and Grievances

There are separate procedures for filing an appeal or grievance that involves your Medicare Part D drug benefits. For more information, please see the Medicare Drug Benefit Grievance and Appeal.

What is a Grievance or an Appeal

What Is An Appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving.

For example, you can file an appeal:

  • If CCHP refuses to cover or pay for services or benefits you think should be covered;
  • If CCHP or one of the Plan providers refuses to give you a service you think should be covered;
  • If CCHP or one of the Plan providers reduces or cuts back on services or benefits you have been receiving; or
  • If you think CCHP is stopping your coverage of a service or benefit too soon.

    What Is A Grievance

    A grievance is a type of complaint you make about CCHP or one of our network providers or pharmacies, including a complaint concerning the quality of your care or service. This type of complaint typically does not involve coverage of services or drugs or payment disputes.

    For example, you would file a grievance if you have a problem with:

  • The quality of your care;
  • Waiting times for appointments or in the waiting room;
  • The way your doctors or others behave;
  • Being able to reach someone by phone or get the information you need; or
  • The cleanliness or condition of the doctor's office.


    • How to File an Appeal

    To start an appeal you, your doctor, or your representative, can call Member Services at 1-415-834-2118 or 1-888-775-7888 (TTY/TDD: 1-877-681-8898), 7 days a week from 8:00 a.m. to 8:00 p.m. You must file an appeal in writing by submitting a signed request form or a written document to tell us what you are appealing and why you are filing an appeal. The appeal request form is available online and at the CCHP Member Services office. You are not required to use this form, however your appeal must be in writing.

    Your doctor or other provider can request a coverage decision appeal or reconsideration for you. An example of coverage decision appeal or reconsideration would be when CCHP denies you coverage for services or durable medical equipment you and your doctor think you need. If you have someone appealing your decision for you other than your doctor, your appeal must include an appointment of representative form authorizing this person to represent you.

    If you have someone appealing your decision for you other than your doctor, your appeal must include an appointment of representative form authorizing this person to represent you. The appointment of representative form is available on the CCHP website and at the Member Services office. While CCHP can accept an appeal request without the appointment of representative form, CCHP cannot complete our review until we receive it. If CCHP does not receive the appointment of representative form or other appropriate legal papers supporting an authorized representative's status within 44 days after receiving your appeal request, your appeal request will be sent for dismissal.

    You must make your appeal request within 60 calendar days from the date of the denial letter, informing you of the Plan's decision to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, CCHP may be able to give you more time to make your appeal.

    Please send your request to:

    Chinese Community Health Plan
    Member Services
    445 Grant Avenue, Suite 700
    San Francisco, CA 94108

    How to File A Grievance

    Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know.

    If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

    Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you experienced the problem you want to complain about.


    CCHP must notify you of the decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. CCHP may extend the time frame by up to 14 calendar days if you request the extension, or if the Plan justifies a need for additional information and the delay is in your best interest.

    What Happens After You File A Grievance

    Within 5 days after receiving your request, CCHP will send you a letter letting you know that your complaint has been received. Within 30 days after your request was received, CCHP will send you a written notice with an answer and the next steps in the process if you are not satisfied with the response.

    Expedited Review

    You can ask for a fast appeal or grievance if you or your doctor believes that waiting too long for a decision could seriously harm your health. You may call, send or fax your request to Members Services. CCHP must decide on a fast appeal or grievance no later than 72 hours after the request is received.

    Complete Details

    For more detail about the appeal and grievance procedures, please review your CCHP Evidence of Coverage.

    Please click on the plan year tabs (2012) below for downloadable PDFs.

     

    Medicare Resources

    Medicare
    Medicare Ombudsman
    Medicare Complaint Form
    CMS Website Best Available Evidence Policy Page
    Request for Redetermination of Medicare Prescription Drug Denial
    Request for Medicare Prescription Drug Coverage Determination


    H0571_2012_171 CMS Approved MMDDYYYY Pending CMS Approval
    Last updated 02022012