Grievances

If you have a problem or are not happy about a service you received with Contra Costa Health Plan Care Plus (HMO D-SNP) or our providers, you can file a complaint or grievance.

What is a grievance?

A grievance is any expression of dissatisfaction with any aspect of CCHP Care Plus operations or its activities or behavior of the plan or its delegated entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. Grievances also include complaints about the quality of care you may receive.

What is a Quality of Care Grievance?

A Quality of Care grievance is a complaint related to whether the quality of covered services provided by a plan or provider meets professionally recognized standards of health care, including whether appropriate health care services have been provided or have been provided in appropriate settings.

You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us).

The Quality Improvement Organization 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.

To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, of your Member Handbook. If you make a complaint to this organization, we will work with them to resolve your complaint

Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

Who can file a grievance?

You or your appointed representative (someone you name to act for you) may file a grievance. You can name a relative, friend, attorney, doctor, or someone else to act for you. You may have someone already authorized under state law to act on your behalf or an individual appointed with power of attorney for example.

If you don’t and wish to have someone represent you, use the appointment of representative form required by the Centers for Medicare and Medicaid Services (CMS). This form is for use for appeals, coverage decisions, or grievances and is valid for one (1) year from the date from the date it has your signature and the signature of your appointed, unless revoked. 

How long do you have to file a grievance?

You must file your grievance no later than 60 calendar days after the event or incident that precipitated or caused the grievance. If CCHP Care Plus needs 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 respond to your grievance.

For more information regarding the Medicare Grievance Process, please refer to the chapter entitled "What to do if you have a problem or complaint” in your Evidence of Coverage.

How long does CCHP Care Plus have to make a decision about your grievance?

We have 30 calendar days to respond to your grievance. Upon completion of our review, we will notify you by phone or in writing. We will address all issues identified by you in your grievance and the reasons for our response. All grievances submitted to CCHP Care Plus in writing (mail, fax or email) including quality of care grievances will be answered in writing.

How do you file an expedited or fast grievance?

You have the right to an Expedited or Fast Grievance Process if CCHP Care Plus denied your request for a "fast coverage decision" or a "fast appeal," or if we extended a coverage decision or appeal time frame about your request for Part C medical care. 

Once we receive the expedited grievance, a Clinical Practitioner will review the case to determine the reasons for the denial of your request for a fast review or if the case extension was appropriate.

Appeals

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.

What is an appeal?

An appeal is a formal way for you to request reconsideration or redetermination of a decision made by the plan. This includes, for example, a decision not to pay for a service or medication. You can file an appeal if you disagree with this decision.

Who may file an appeal?

You or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. You may have someone already authorized under state law to act on your behalf or an individual appointed with power of attorney for example.

If you don’t and wish to have someone represent you, download the appointment of representative form required by the Centers for Medicare and Medicaid Services (CMS). This form is for use for appeals, coverage decisions, or grievances and is valid for one (1) year from the date from the date it has your signature and the signature of your appointed, unless revoked.  

How long do you have to request an appeal?

You have sixty-five (65) calendar days from the date of the notice your received to file an appeal with CCHP Care Plus.

How long does it take CCHP Care Plus to make a decision?

CMS requires CCHP Care Plus to make timely decisions about requests for reconsideration or redetermination of its decision to deny a service or drug. Our timeframes for making a decision start upon receipt of your request to appeal as follows:

Part C or Medical Reconsiderations

Pre-Service:
Standard: 30 calendar days
Expedited (medical condition requires a "faster" decision) or Part B drug: 72 hours

Post-Service:
60 calendar days

Part D or Drug Redeterminations

Pre-Service:
Standard: 7 calendar days
Expedited (medication condition requires a "faster" decision): 72 hours

For some appeals you or we may need additional time. CMS allows an additional 14 calendar days if you ask for more time or if we need information that may benefit you in making our decision. If we decide to take extra time, we will tell you orally and in writing.

Ways to file a Grievance or Appeal

• Call Member Services toll-free: 1-844-729-8411 (TTY: 711), 8 a.m. to 8 p.m. We have free interpreter services.
  If you have a clinically urgent issue, you can reach our 24-hour Advice Nurse at 1-877-661-6230 (Option #1) (TTY 711). The 24-Hour Nurse-Advice Line is open on the weekends and holidays.
  
  
• Write about the issue in a letter or on a Member Grievance / Appeals pdf form that you can download and print.
  
  Mail to:
  Contra Costa Health Plan
  Attn: Appeals & Grievances Department
  595 Center Avenue, Suite 100
  Martinez, CA 94553
  
  By Fax: 1-925-313-6047
  
  
• Online – File a grievance by filling out and submitting the online form