CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2023
Problems & Complaints
If you are dissatisfied with your medical care or the service provided by HPSM or your doctor's office, we want to address and resolve it to your satisfaction. Our grievance and appeals process allows us to do this as quickly as possible.
Expressing concerns or filing a complaint will not affect your benefits in any way. Your provider (doctor) also cannot discriminate against you because you file a complaint.
Please note: Complaints related to Medi-Cal Rx pharmacy benefits are not subject to the HPSM grievance and appeals process. Members can submit complaints about Medi-Cal Rx pharmacy benefits by calling 1-800-977-2273 (TTY 1-800-977-2273 and press 5 or 7-1-1) or going to medi-calrx.dhcs.ca.gov. However, complaints related to pharmacy benefits not subject to Medi-Cal Rx may be eligible for an Independent Medical Review. DMHC’s toll-free telephone number is 1-888-466-2219 and the TTY line is 1-877-688-9891. You can find the Independent Medical Review/Complaint form and instructions online at the DMHC’s website: www.dmhc.ca.gov/.
How to file a complaint
First, call the CareAdvantage Unit:
- 1-866-880-0606 or 650-616-2174
- TTY: 1-800-735-2929 or 7-1-1
- Hours: Monday - Sunday, 8:00 a.m. to 8:00 p.m.
The CareAdvantage Unit will try to resolve your concern over the phone. If they do not resolve your complaint to your satisfaction within 24 hours, the Grievance and Appeals Unit will start a formal process to reach a solution.
Grievance and Appeals
There are two types of complaints, a grievance and an appeal
- File a grievance if you are dissatisfied with the medical services or customer service you received from HPSM or a provider
- You can file a complaint at any time
- File an appeal if you want HPSM to reconsider a decision to deny coverage for a service or item you or your doctor requested
- You must file within 60 days of the event
There are three ways you can file a grievance
- Online: Fill out and submit our online confidential complaint form.
- By phone: Call the CareAdvantage Unit at 1-866-880-0606 (toll-free) or 650-616-2174
- In writing: Fill out our printable member complaint form, then either fax it to 650-829-2002 or mail it to HPSM Grievance and Appeals using the address on the form.
To file an appeal
- Call a CareAdvantage Navigator: at 1-866-880-0606 (toll-free) or 650-616-2174
Complaints about emergency situations
If your complaint involves an imminent and serious threat to your health (including but not limited to severe pain, potential loss of life, limb or major bodily function), you or your provider may request an expedited (fast-tracked) review. If your complaint qualifies, we will resolve it within three days of receipt.
After you file a complaint
Within five (5) business days of receiving your complaint, an HPSM Grievance and Appeals Coordinator will call you to discuss your complaint and review HPSM's complaint process. We will resolve your complaint within 30 days and send you a letter explaining our decision. To ask about the status of an existing complaint, call our Grievance and Appeals Unit.
Any services that were authorized will continue to be provided until your complaint is resolved.
To file a complaint with Medicare, call 1-800-Medicare (1-800-633-4227) or click on the following link to complete a complaint form on the Medicare website:Medicare Complaint Form
You can also contact the Cal MediConnect Ombudsman Program at 1-855-501-3077 for assistance.
CareAdvantage Dual Eligible Special Needs Plan (D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the CareAdvantage 2023 Member Handbook.
Benefits and co-pays may change on January 1 of each year.
If you speak other languages other than English, language assistance services, free of charge, are available to you. Call 1-866-880-0606 (TTY: 1-800-735-2929 or dial 7-1-1). ( Download this statement in multiple languages.)
Page updated October 1, 2022