Making a Complaint

What kinds of problems should be complaints?

The complaint process is used for certain types of problems only, such as problems related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the complaint process.

Complaints about quality

You are unhappy with the quality of care, such as the care you got in the hospital.

Complaints about privacy

You think that someone did not respect your right to privacy, or shared information about you that is confidential.

Complaints about poor customer service

A health care provider or staff was rude or disrespectful to you. L.A. Care Cal MediConnect Plan staff treated you poorly. You think you are being pushed out of the plan.

Complaints about physical accessibility

You cannot physically access the health care services and facilities in a doctor or provider’s office.

Complaints about waiting times

You are having trouble getting an appointment, or waiting too long to get it. You have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other plan staff.

Complaints about cleanliness

You think the clinic, hospital or doctor’s office is not clean.

Complaints about language access

Your doctor or provider does not provide you with an interpreter during your appointment.

Complaints about communications from us

You think we failed to give you a notice or letter that you should have received. You think the written information we sent you is too difficult to understand.

Complaints about the timeliness of our actions related to coverage decisions or appeals

You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal. You believe that, after getting a coverage or appeal decision in your favor, we are not meeting the deadlines for approving or giving you the service or paying you back for certain medical services. You believe we did not forward your case to the Independent Review Entity on time.

Details and deadlines

Call Member Services at 1-888-522-1298 (TTY: 711). Complaints related to Medicare Part D must be made within 60 calendar days after you had the problem you want to complaint about. All other complaints must be filed with us or the provider within 180 calendar days from the day the incident occurred that caused you to be dissatisfied. If there is anything else you need to do, Member Services will tell you. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can make a complaint if we have asked to delay a decision for an appeal. We will automatically give you a “fast complaint” and respond to your complaint in 24 hours. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint” and respond to your complaint within 24 hours. If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, you can request a “fast complaint” and we will respond within 72 hours. Most complaints are answered in 30 calendar days. If we need 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 your complaint. If we do not agree with some or all of your complaint we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.

You can file complaints with the Office of Civil Rights

If you have a complaint about disability access or about language assistance, you can file a complaint with the Office of Civil Rights at the Department of Health and Human Services 1-800-368-1019 (TTY: 1-800-537-7697). You may also have rights under the Americans with Disability Act and under Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, all other laws that apply to organizations that get Federal funding and any other laws and rules that apply for any other reason. You can contact the Cal MediConnect Ombuds Program for assistance.

You can make complaints about quality of care to the Beneficiary and Family-Centered Care Quality Improvement Organization

When your complaint is about quality of care, you also have two choices: If you prefer, you can make your complaint about the quality of care directly to the Beneficiary and Family-Centered Care Quality Improvement Organization (without making the complaint to us). Or you can make your complaint to us and also to the Beneficiary and Family-Centered Care Quality Improvement Organization. If you make a complaint to this organization, we will work with them to resolve your complaint. The Beneficiary and Family-Centered Care 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. The phone number for the Beneficiary and Family-Centered Care Quality Improvement Organization is 1-866-800-8749 (TTY: 1-800-881-5980).

You can tell Medicare about your complaint

You can also send your complaint to Medicare through the Medicare Complaint Form. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.

You can tell Medi-Cal about your complaint

The Cal MediConnect Ombuds Program also helps solve problems from a neutral standpoint to make sure that our members receive all the covered services that we are required to provide. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan. The phone number for the Cal MediConnect Ombuds Program is 1-855-501-3077. The services are free.

Getting more Information

For help or more information, contact Member Services by:

Phone: 1-888-522-1298 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.

How to Request an Aggregate Number of Complaints (Grievances), Appeals, and Exceptions

You can request an aggregate number of complaints (grievances), appeals, and exceptions filed with L.A. Care Cal MediConnect by contacting us. If you request that the information be sent to you in writing, the information will be mailed to you within seven (7) to ten (10) business days.

You can contact Member Services by:

Phone: 1-888-522-1298 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.

Fax: Submit written requests to 1-213-438-5748

Mail: Submit written requests to:

L.A. Care Health Plan
Attn: Grievance and Appeals Unit
P.O. Box 811610
Los Angeles, CA 90081

For Members Affected by the Wildfires

L.A. Care wants to ensure you have access to needed health services as our state deals with the current wildfire disaster. If you have been impacted by the wildfires, please note the following:

  • Prescriptions can be refilled at an out-of-network pharmacy if medications have been lost or left behind. Call 1-888-839-9909 for further assistance.
     
  • Clinical Services can be accessed out-of-network if your usual provider is unable to work due to the wildfires. Call 1-888-522-1298 for guidance in this situation.

Medical transportation, mental health services and additional information is available at the L.A. Care website.

 

H8258_15129_2015CMC
CMS Approved
Updated 06/14/2016

 

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