GRIEVANCE FORM

Grievance and Appeal Process for Community Advantage Plus (HMO D-SNP)

A Medicare Plan for People with Medicare and Medi-Cal

Because you are covered by both Medicare and Medi-Cal (Medicaid), there are separate processes available for handling grievances (complaints) and appeals. These processes are reviewed and approved by Medicare and Medi-Cal, and each comes with its own rules, timelines, and procedures.

  • If your concern involves a Medicare-covered benefit, you must use the Medicare process.
  • If it involves a Medi-Cal-covered benefit, you must use the Medi-Cal process.

If you are unsure which process applies, you can call Member Services at 1-888-484-1412 (TTY: 711) and we will guide you.

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    How to File a Grievance

    Medicare Grievance Process

    As a member of Community Advantage Plus, we encourage you to let us know if you have concerns or problems related to your coverage or the care you receive. Community Advantage Plus Member Services staff are always ready to help you solve any problems you have about your care. Our Customer Service staff will work with you to resolve any complaint that you may have. You can file the grievance at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem.

    What is a Grievance?

    A grievance is a formal complaint about issues such as the quality of care you received, the service you experienced from a provider or pharmacy, or other concerns related to Community Health Plan of Imperial Valley (CHPIV). You or your authorized representative may file a grievance. You can file a grievance at any time (except for Part D drug issues, which must be submitted within 60 days of the problem).

    How to submit a Grievance:

    You may file a grievance by contacting the Community Advantage Plus Member Services Department toll free at 1-888-484-1412 (TTY: 711). Community Advantage Plus Plan representatives are available 24 hours a day, 7 days a week, including holidays. You may also opt to submit your grievance in a letter and send it directly to Community Advantage Plus at the following address:

    CHPIV Community Advantage Plus
    Attention: Grievance & Appeals Supervisor
    P.O. Box 174 Imperial, CA 92251

    You will receive a written letter telling you that Community Advantage Plus received your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of Community Advantage Plus receiving your grievance. For questions about the status of your grievance, call the Member Services Department at 1-888-484-1412 (TTY: 711).

    Grievance Process

    Types of Grievances:

    Fast Grievance (24 hours): If you disagree with our decision not to expedite a care decision or if we extend a decision timeframe, you, your doctor, or your representative can request a fast grievance. We will respond by phone within 24 hours and provide a written notice within three calendar days.

    Standard Grievance (30 days): Any other type of complaint must be addressed within 30 calendar days, or sooner if your health requires it.

    Appointment of Representative

    You have the option to appoint a representative to act on your behalf and request an organization / coverage determination, formulary exception, grievance and/or an appeal. 

    You can name a relative, friend, advocate, doctor, or someone else to act for you. If you want to name someone to act on your behalf, you and the person you would like to act on your behalf must fill out the “Appointment of Representative” form. When completed, this form allows this person legal permission to act as your authorized representative. Please click on the following link to access the Appointment of Representative Form:

    Download Appointment of Representative Form (English)
    Download Appointment of Representative Form (Spanish)

    The completed form should be faxed, mailed, or delivered in person to: 

    CHPIV Community Advantage Plus
    Attention: Grievance & Appeals Supervisor
    P.O. Box 174 Imperial, CA 92251

    In addition, an individual authorized under state or other applicable law, could include, but is not limited to:

    • Court appointed guardian
    • Individual with durable power of attorney
    • A health care proxy
    • A person designated under a health care
    • Consent statute
    • Executor of an estate

    A representative form is not required. An authorized individual must produce appropriate legal papers supporting his or her status under state or other applicable law.

    How to File a Medicare Coverage Decision (Organization or Coverage Determination)

    To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

    CHPIV Community Advantage Plus
    P.O. Box 174 Imperial, CA 92251

    How long does it take to get a coverage decision?

    You, your doctor, or your representative may ask us to make a coverage decision. Requests may be submitted by phone, fax, or mail.

    Standard coverage decision:

    • We generally provide a decision within 5 business days, or 72 hours for Medicare Part B prescription drugs.
    • In some cases, we may extend up to 14 additional calendar days, but not for Part B drugs.

    Fast coverage decision:

    • If waiting could harm your health, you may request a fast decision.
    • Decisions are made within 72 hours, or 24 hours for Medicare Part B drugs.
    • If your doctor supports the request, we will automatically provide a fast decision.
    Asking for a fast coverage decision:

    • Start by calling or faxing (1-760-563-5187)  to ask us to cover the care you want.
    • You can call us at 1-888-484-1412 (TTY: 711). For details on how to contact us, see the Member Handbook.
    • You can also have your doctor or your representative call us to request a fast coverage decision.
    Rules for asking for a fast coverage decision:

    You must meet the following two requirements to get a fast coverage decision:

    • You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you have already received.)
    • You can get a fast coverage decision only if the standard 14-calendar day deadline (or 72 hour deadline for Medicare Part B prescription drugs) could cause serious harm to your health or hurt your ability to function.

    If your doctor says that you need a fast coverage decision, we will automatically give you one.

    • If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.
    • If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter informing you. We will also use the standard 14 calendar day (or 72 hours deadline for Medicare Part B prescription drugs) deadline instead.
    • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of a fast coverage decision. 

    Appeals

    You may file an appeal if we deny coverage, payment, or stop a service or drug you believe should be provided. You, your doctor, or your appointed representative must file a written request for appeal within sixty (60) calendar days from the date of the notice of the coverage decision (i.e., the date printed or written on the notice). You must send your appeal in writing to:

    CHPIV Community Advantage Plus
    Attention: Grievance & Appeals Supervisor
    P.O. Box 174 Imperial, CA 92251

    You should include your name, address, subscribe ID number, reason for appealing and any evidence that you wish to attach. You may include supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person to the fax number or address above.

    You will receive a written letter telling you that Community Advantage Plus received your appeal, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of  Community Advantage Plus receiving your appeal.

    For additional information regarding the Community Advantage Plus appeal process, please see the Member Handbook.

    For questions about the status of your appeal, or to get information about the number of grievances, appeals and exceptions filed with Community Advantage Plus Plan, contact the Member Services Department at 1-888-484-1412 (TTY: 711). Community Advantage Plus Plan representatives are available 24 hours a day, 7 days a week, including holidays.

    There are five levels of the appeal process:

    Appeal Level 1

    If we deny any part or your entire request to cover or pay for service you, your treating physician or your appointed representative may ask us to reconsider or “appeal” our decision. There are two kinds of appeals that you can file:  

    1. Standard Appeal:  
      • For care you have not yet received: You, a physician who is treating you and acting on your behalf and has provided notice to you, or another person you name (such as your lawyer or a family member) may ask for a standard appeal regarding medical care or services you have not yet received.  
      • For a decision about medical care or services you have not yet received, we will give you a decision within 30 calendar days, but will make it sooner if your health condition requires it.
      • For a decision about payment for care or services, you already received: You or another person you name (such as your lawyer or family member) may ask for a standard appeal. Community Advantage Plus will give you a decision no later than 30 calendar days after we get your appeal. If we do not decide within 30 calendar days, your appeal automatically goes to Appeal Level 2.
    2. Fast Appeal:  
      • You, any doctor acting on your behalf or your representative can ask us to give a fast appeal for services or care you have not yet received. We will give you a decision about your medical care within 72 hours after you or your doctor asks for it sooner if your health requires. If any doctor asks for a fast appeal for you, or supports you in asking for one, Community Advantage Plus will automatically give you a fast appeal.
      • If you or your appointed representative asks for a fast appeal without support from a doctor, Community Advantage Plus will review your request. If we do not grant your request for a fast appeal, we will send you a letter within three calendar days notifying you that we will make our decision within the standard timeframe of 30 calendar days. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast appeal, and will explain that we will automatically give you a fast decision if you get a physician’s support for a fast appeal.

    Appeal Level 2

    If denied, the case is automatically sent to an Independent Review Entity (IRE).

    Appeal Level 3

    If still denied, you may request review by an Administrative Law Judge.

    Appeal Level 4

    Further review may be requested from the Medicare Appeals Council.

    Appeal Level 5

    Final option is judicial review by filing in a U.S. District Court.

    State Fair Hearing Process

    The Department of Social Services administers a Fair Hearing process. You have a right to a State Fair Hearing if services that your doctor asked to have been denied or stopped. If you get a written notice denying health services, that notice will include a form for you to file a grievance with CHPIV. However, it is your right to ask for a State Fair Hearing with or without filing a grievance with us or waiting for a decision from us about your grievance.

    To be eligible for a State Fair Hearing, you must ask for it within 120 days of receiving our decision to deny or stop services. To ask for a hearing, call the Department of Social Services at 1-800-952-5253, TTY users should call 1-800-952-8349 or send a letter asking for the hearing to:

    California Department of Social Services
    State Hearings Division
    P.O. Box 944243, MS 21-37
    Sacramento, CA 94244-2430

    If you need help with asking for a State Fair Hearing, please call Member Services at 1-888-484-1412 (TTY: 711). If you are granted a State Fair Hearing, you may represent yourself or be represented by an authorized third party such as legal counsel, relative, friend or any other person.

    Some grievances, due to their urgency, may be eligible for an Expedited State Hearing (ESH). For more information on expedited State Fair Hearing, please refer to the Member Handbook.

    Department of Managed Health Care

    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 1-888-484-1412 (TTY: 711) 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.

    You are not required to participate in CHPIV’s grievance process before seeking an IMR of our decision to deny coverage of an experimental/ investigational therapy.

    An IMR is available in the following situations: 

    1. (a) Your doctor has recommended a health care service as medically necessary, or
      (b) You have gotten urgent care or emergency services that a doctor determined was medically necessary, or
      (c) You have been seen by an in-plan doctor for the diagnosis or treatment of the health condition for which you seek independent review, without a provider recommendation in (a) above or urgent or emergency services in (b) above. The in-plan provider need not recommend the disputed health care service as a condition for the enrollee to be eligible for an IMR. The provider may be an out-of-plan provider. However, the plan will not have liability for payment of services unless required by the director for services determined from the IMR to be a medically necessary covered benefit or reasonable under the emergency or urgent medical circumstances; and 
    2. The disputed health care service has been denied, modified, or delayed by CHPIV or one of its plan doctors, based in whole or in part on a decision that the health care service is not medically necessary; and
    3. You have filed a grievance with CHPIV and the disputed decision was upheld or the grievance remains unresolved after 30 calendar days.

    If your grievance is eligible for expedited review, you are not required to file a grievance with CHPIV before asking for an IMR. If there is an imminent and serious threat to the health of the enrollee, all necessary information and documents shall be delivered to an independent medical review organization within 24 hours of approval of the request for review. In addition, the DMHC may waive the requirement that you follow CHPIV’s grievance process in extraordinary and compelling cases. 

    For cases that are not urgent, the IMR organization designated by DMHC will provide its determination within thirty (30) days of receipt of your application and supporting documents. For urgent cases involving an imminent and serious threat to your health, but not limited to severe pain, potential loss of life, limb or major bodily function; the IMR organization will provide its determination within three (3) calendar days of the receipt of the information. At the request of the experts, the deadline can be extended by up to three (3) calendar days if there is a delay in getting all needed documents. 

    The IMR process is in addition to any other procedures or remedies that may be available to you. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan about the care that was requested. You pay no application or processing fees for an IMR. You have the right to provide information in support of your request. For more information about the IMR process or to ask for an application form, please call CHPIV’s Member Services at 1-888-484-1412 (TTY: 711). The hearing impaired may call Member Services through the California Relay Service at 1-(800) 735-2929.

    If you do not agree with the plan’s decision, you may ask for an Independent Medical Review (IMR) and/or a State Hearing (SH). This includes non-covered benefits, and services that are medically necessary. To ask for an IMR, you may call the Department of Managed Health Care (DMHC). DMHC will let you know if an IMR is an option for you. You may call DMHC at the toll-free telephone number at 1-888-466-2219 and the TDD line at 1-877-688-9891 for the hearing and speech impaired. You can also go to DMHC’s internet website at www.dmhc.ca.gov for IMR application forms. To ask for a SH, you may call the California Department of Social Services (CDSS) at 1-800-743-8525 and the TDD line at 1-800-952-8349 for the hearing and speech impaired. You can also go to CDSS’s internet website at www.cdss.ca.gov for SH forms. 

    For more information, please refer to the ‘Your Rights’ letter enclosed with your notice of denial.

    Medicare Electronic Complaint Form

    To download a blank copy of the Medicare Electronic Complaint Form, click https://www.med icare.gov/MedicareComplaintForm/home.aspx

    You may also access additional information on how to file a complaint on Medicare’s website at https://www.medicare.gov/

    Requesting information about Grievances and Appeals

    If you want to request data information about grievances and appeals, please call Member Services at 1-888-484-1412 (TTY: 711) for more information.

    Disclaimers

    Community Advantage Plus (HMO D-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in Community Advantage Plus depends on contract renewal.

    ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-484-1412 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

    ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas disponibles sin cargo. Llame al 1-888-484-1412 (TTY: 711). Las llamadas a estos números son gratuitas.

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