Grievance Process
Grievance Definition
A grievance is a written or oral expression of dissatisfaction regarding VOC and/or a provider, including quality of care concerns, complaints, disputes, requests for reconsideration or appeals made by a member or the member’s representative
Grievance Process
VOC has a grievance procedure for receiving and resolving your grievances involving VOC and providers. A grievance may be submitted up to 180 calendar days following receipt of an adverse determination notice, or following any incident or action that is the subject of the member’s dissatisfaction. You may submit a grievance to VOC in writing, in person, by telephone, by facsimile, by e-mail, or online at this web site or upon request, we will mail a grievance form and a copy of our Grievance Procedure. If you wish, a Customer Service representative will assist you in completing the grievance form.
To submit a grievance, you may call us at 1-800-228-1286 extension: 2425. Completed grievance forms may be submitted online through a secure means at this web site or must be mailed or delivered to ValueOptions® of California ATTN: Grievance Unit P.O. Box 6065 Cypress, CA 90630-0065. You may also submit a grievance in person at this same address.
We will send you written acknowledgment of receipt of a grievance within five (5) calendar days. We will respond in writing with a resolution to a grievance within thirty (30) calendar days of receipt.
Urgent Grievances
VOC also maintains a process for the expedited review of urgent grievances. You have the right to an expedited review for cases involving an imminent and serious threat to the health of the member, including but not limited to severe pain, potential loss of life, limb, or major bodily functions. The request may be initiated by you or by your provider. Call 1-800-228-1286 extension: 2425 and tell the representative that you are requesting an expedited review for an urgent grievance. We will notify your provider of the decision in no more than 72 hours and send you a written statement on the disposition or pending status of the grievance within the same 72 hours from receipt of the grievance.
Additional Review
If you are not satisfied with our response to a grievance, you may submit a request to VOC for voluntary mediation or binding arbitration within sixty (60) days of receipt of our response. These processes are described in your Combined Evidence of Coverage and Disclosure Form or you may call us for information on how to submit a voluntary mediation or arbitration request.
You may file a grievance with the Department of Managed Health Care after completing the VOC grievance process or voluntary mediation or after participating in the VOC grievance process or voluntary mediation for thirty (30) days.
Independent Medical Review
You may request an independent medical review (“IMO”) of Disputed Behavioral Health Care Services from the Department of Managed Health Care if you believe that behavioral health care services have been improperly denied, modified, or delayed by VOC. A “Disputed Behavioral Health Care Service” is any mental health or substance abuse care service eligible for coverage and payment under your subscriber contract that has been denied, modified, or delayed by VOC, in whole or in part because the service is not medically necessary.
The IMR process is in addition to any other procedures or remedies that may be available to you. You pay no application or processing fees of any kind for IMR. You have the right to provide information in support of the request for IMR. VOC will provide you with an IMR application form with any grievance disposition letter that denies, modifies, or delays behavioral health care services. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against VOC regarding the Disputed Behavioral Health Care Service.
The IMR process is described in your Combined Evidence of Coverage and Disclosure Form or you may call us for information on how to submit an IMR request.
Review by the Department of Managed Health Care
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 (1-800-228-1286 extension: 2425) 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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
