File a Member Grievance or Appeal

If you have a problem or are not happy about a service you received, you can file a complaint or grievance.

If you want CCHP to change a decision we made about denying, delaying, or modifying a service that was requested, you can file an appeal.

You will get a letter to let you know we received your complaint (grievance) or appeal. CCHP will review and resolve your case within 30 calendar days. If you or your doctor believe that taking up to 30 calendar days to resolve your complaint (grievance) or appeal would put your life, health or ability to function in danger, you can ask for an expedited (fast) review for a resolution within 72 hours.

If you want to allow someone else, such as a family member or friend to help you file a grievance or appeal on your behalf, we will contact you for verbal permission to process it. If you want someone else to continuously represent you, you must sign and submit a Personal Representative Request Form.

If you have Medi-Cal and file an appeal by phone or through our online form, you will need to follow up with a signed statement in writing. If you have Medi-Cal and your provider files an appeal on your behalf, you will need to mail or fax us a signed Member Consent Form.

You can find more information about grievances & appeals in your Member Handbook / Evidence of Coverage (EOC).

Ways to file a grievance or appeal

Fill out the online grievance / appeal form below.

OR

Call Member Services, Monday – Friday, 8am – 5pm at 1-877-661-6230 (Option 2) (TTY 711). If you have a clinically urgent issue, you can also reach our 24 Hour Nurse Advice Line at 1-877-661-6230 (Option 1). (TTY 711). The 24 Hour Nurse Advice Line is open even on weekends and holidays.

OR

 

Write about the issue in a letter or on a Member Grievance / Appeals pdf form that you can download and print. Mail or fax it to:

Contra Costa Health Plan
Attn: Grievance/Appeal
595 Center Ave., Suite 100
Martinez, CA 94553
Fax: 925-313-6047

Online Grievance/Appeal Form

Member Name	First Name	MI	Last Name
Date of Birth (mm/dd/yyyy)
Member ID Number
Phone (include extension if needed)
Email see our privacy policy
Address
Date of Service (mm/dd/yyyy)
Location of Service
Briefly Describe Complaint (Please include as much detail as possible including names of the people involved, the circumstances leading up to the conflict, and any information you feel is important to the complaint. If your complaint is about medications or medical supplies, tell us which medication(s)/supplies you need and how many days of medications / supplies you have left.)
What action are you requesting?

Information Needed to File an Appeal

Appeal/Reconsideration requests can be made to the Health Plan by the member if they have received a Notice of Action (NOA) letter concerning a denial of a claim or a delay, modification or denial of a requested service. The request can be made by phone or on-line but must be followed up in writing and signed by the member or the member’s legal representative. For our Medi-Cal members this request must be made within 60 days of receipt of a NOA. For our Commercial member this request must be made within 180 of a receipt of a NOA. Date of Notice of Action (NOA) Denial Letter:

Description of a Regular Appeal (Please include as much detail as possible including date of the denial of the claim or service and any additional information you feel is important to consider. The Health Plan has 30 days to respond to your appeal and you will get a final notice of resolution)

Description of an Expedited Appeal (If you think waiting 30 days for the Health Plan to respond, will hurt your health, you might be able to get a response within 72 hours. When filing your appeal, say why waiting will hurt your health. Make sure you ask for an "expedited appeal". Please include as much detail as possible including date of the denial of service and any additional information you feel is important to consider. The Health Plan has 72 hours to respond to your expedited appeal and you will get a final notice of resolution)

Person Completing form if other than member
Name of Person Submitting form
Relationship	Spouse     Parent     Grandparent Guardian if none of the above, please specify:
Phone

I authorize that all information pertaining to this grievance/appeal, possibly including medical records and clinical information, be shared with the Contra Costa Health Plan for the express purpose of resolution of this grievance/appeal. (Please check to agree/proceed.) If not authorized by member or member's legal guardian, we will be unable to process grievance/appeal without member's explicit agreement.

Enter security numbers:

If you experience any difficulties with this form, please contact us at 1-877-661-6230 (press 2). (TTY 711)

FILING A COMPLAINT WITH DEPARTMENT OF MANAGED HEALTH CARE (DMHC)

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 (Contra Costa Health Plan 1-877-661-6230 Press 2) 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.