Getting Help

Let Member Services try to solve your problem first

Most problems can be resolved by one of our Member Services Representatives. If you have a problem, please call L.A. Care Cal MediConnect Plan Member Services first so that we may try to find a solution.

Phone: 1-888-522-1298 (TTY: 711)
If you have concerns, call L.A. Care Cal MediConnect Plan Member Services, 24 hours a day, 7 days a week, including holidays.

You can get help from the Cal MediConnect Ombuds Program

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 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. The services are free. You can contact the Cal MediConnect Ombuds Program by:

Phone: 1-855-501-3077

You can get help from the Health Insurance Counseling and Advocacy Program (HICAP)

You 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. You can contact the local HICAP office by:

Phone: 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920)

Getting help from Medicare

You can call Medicare directly for help with problems. Here are two ways to get help from Medicare, by:

Phone: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week.

Web: Visit the Medicare website at www.medicare.gov

Getting help from Medi-Cal

You can call the Cal MediConnect Ombuds Program directly for help with problems with Medi-Cal.
You can contact the Cal MediConnect Ombuds Program by:

Phone: 1-855-501-3077

Web: You can also visit the Office of the Patient Advocate website www.opa.ca.gov

You may also file a complaint with the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) for California, Livanta. You may contact the BFCC-QIO by:

Mail: Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

Phone: 1-877-588-1123 (TTY: 1-855-887-6668), 24 hours a day, seven days a week
Fax: Appeals – 1-855-694-2929; All other reviews – 1-844-420-6672

Appointing a Representative

Appointing a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, you can make this request by:

Phone: Call Member Services and ask for the Appointment of Representative Form, to give that person permission to act on your behalf.

Mail: You may also send a written statement authorizing the individual to act on your behalf. The form or statement must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form or statement indicating that the individual accepts the appointment. Please send the completed form or statement to:

L.A. Care Cal MediConnect Plan
Attn: Grievances & Appeals Unit
P.O. Box 811610
Los Angeles, CA 90081

Fax: Or fax the signed form or statement to 213-438-5748

You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of decision or appeal a decision.

Related documents:

Appointment of Representative Form (pdf)

Overview of Organization/Coverage Determinations & Appeals

The process for asking for coverage decisions and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except Part D co-pays.

What is a coverage decision?

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

What is an appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal.

Getting help with coverage decisions and appeals

You can ask any of these people for help:

You can call us at Member Services at 1-888-522-1298 (TTY: 711).

Call the Cal MediConnect Ombuds Program for free help. The Cal MediConnect Ombuds Program helps people enrolled in Cal MediConnect with service or billing problems. The phone number is 1-855-501-3077.

Call the Health Insurance Counseling and Advocacy Program (HICAP) for free help. HICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920).

Call your local county social services office for questions about coverage decisions for In-Home Supportive Services (IHSS). The phone number is 1-877-597-4777.

Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf. Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. You can also get the form on the Medicare website or under the “Appointing a Representative” section of this website. The form will give the person permission to act for you. You must give us a copy of the signed form.

You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.

 

H8258_15129_2015CMC
CMS Approved
Updated 06/14/2016

 

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