An appeal is when you ask us to review a decision we made about coverage of a service, the amount we paid or will pay for a service, or the amount you must pay for a service.
You might file an appeal if:
You may file an appeal within 60 calendar days of the date on the letter we sent to tell you of our decision. You might be able to file an appeal even if 60 days have passed since we made our first decision. Tell us in your written request why you could not file within the 60 days allowed.
You or your doctor can ask for a fast (expedited) appeal if you are asking about care you have not yet received and waiting on a decision on a standard appeal could cause serious harm to your health or hurt your ability to function. You cannot get a fast appeal if your request is about payment for care you have already received.
Your doctor or other provider can make an appeal for you. Someone other than your doctor can also make an appeal for you, but they must first complete an Appointment of Representative form.
If you want someone else to file the appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.
A legal surrogate under court order or state law may also be able to file an appeal. Examples of a legal surrogate may include a legal guardian or an individual acting under a power of attorney.
If you need help getting started, you can always call the Cal MediConnect Ombuds program. The Cal MediConnect Ombuds program can answer your questions and help you understand what to do to handle your problem.
The phone number for the Cal MediConnect Ombuds program is 1-855-501-3077. The services are free.
The Cal MediConnect Ombuds program is not connected with us or with any insurance company or health plan. They can help you understand which process to use.
Health Insurance Counseling and Advocacy ProgramYou can also call the Health Insurance Counseling and Advocacy Program (HICAP). The HICAP counselors can answer your questions and help you understand what to do to handle your problem. HICAP is not connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. The HICAP phone number is 1-800-434-0222.
You can call Medicare directly for help with problems. Here are two ways to get help from Medicare:
The following paragraph is a required disclosure under California Health & Safety Code Section 1368.02(b). In this paragraph, the term “grievance” means an appeal or complaint about Medi-Cal services, your health plan, or one of your providers.
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 1-855-817-5785 (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.
Quality Improvement OrganizationWhen your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO). The QIO 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.
In California, the QIO is called Livanta. The phone number for Livanta is 1-877-588-1123
(TTY: 1-855-887-6668).
You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.
You can apply for an IMR if Anthem Blue Cross Cal MediConnect Plan:
You can ask for an IMR if you have also asked for a State Fair Hearing, but not if you have already had a State Fair Hearing on the same issue.
In most cases, you must file an appeal with us before requesting an IMR. See your handbook for information about Anthem Blue Cross Cal MediConnect Plan’s Level 1 appeal process. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.
If your treatment was denied because it was experimental or investigational, you do not have to take part in Anthem Blue Cross Cal MediConnect Plan’s appeal process before you apply for an IMR.
If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may not require you to first follow our appeal process depending on the facts of your case. You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.
To ask for an IMR:
If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.
If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process.
State HearingIf your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have, and we continue to say no after a Level 1 appeal, you have the right to ask for a State Hearing.
In most cases you have 180 days to ask for a State Hearing after the date on your notice of appeal resolution. You have a much shorter time to ask for a hearing if you are currently getting treatment and you want to continue getting treatment.
There are two ways to request a State Hearing:
If we decide to reduce or stop coverage for a prior approved Medi-Cal service you are already receiving, you can request to continue those services during the appeal process. You must make this request within 10 calendar days of our notice to you that we will reduce or stop coverage of the service or the effective date of that notice, whichever is later.
We can take extra days to make a decision in some cases under certain circumstances. If we decide to take extra days to make the decision, we will send you a letter that explains why we need more time.
If we don’t decide in your favor, we’ll send you a letter to tell you. You will have to reach out directly to the Independent Review Entity (IRE) at this stage of the process.
MAXIMUS Federal Services
Part D QIC
3750 Monroe Avenue, Suite 703
Pittsford, NY 14534-1302
Fax: 1-866-825-9507
Customer Service: 1-585-348-3400
If we don’t decide in your favor, your case will be sent to the Independent Review Entity (IRE) for a decision. We’ll send you a letter to tell you if this happens.
Note: If your appeal is about an item or service covered by both Medicare and Medi-Cal and we do not decide in your favor, your case will be sent to the IRE, and you may ask for an Independent Medical Review (IMR) and/or request a State Hearing. If the IRE and the state make different decisions, we’ll follow the decision that is most favorable to you.
Help Center
California Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Fax: 1-916-255-5241
Customer Service: 1-888-466-2219
TTY users should call: 1-877-688-9891
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430
Fax: 1-916-651-5210 or 1-916-651-2789
Customer Service: 1-800-952-5253
TTY users should call: 1-800-952-8349