Provider Manual | Section 3

Member Complaints

Member Complaints

This section describes the procedures that members and their authorized representatives may use to submit complaints to Health Plan of San Mateo (HPSM). The Centers for Medicare and Medicaid Services (CMS) and the State of California have regulations that give health care consumers the right to file a complaint whether the consumer is covered by Medicare, Medi-Cal, or a private insurance plan.

HPSM must follow these federal and state regulations in processing HPSM member complaints. HPSM handles complaints for members in all lines of business: CareAdvantage Cal MediConnect (CMC), Medi-Cal, HealthWorx, and San Mateo County ACE.

Information about the complaints process is included in the Provider Manual because providers may file complaints on behalf of members or assist members in filing a complaint. HPSM may also ask providers for assistance in resolving member complaints through requests for additional medical information or the provider’s perspective on a complaint.

Members have different appeal rights depending upon the line of business in which the member is enrolled. These differences are described in the sections that follow. HPSM members may be dually eligible for both Medicare and Medi-Cal, but not be enrolled in CareAdvantage Cal MediConnect, HPSM’s Medicare line of business. If dually eligible members are covered under Original Medicare, the CareAdvantage procedures described in this section will not apply.

Overview of Member Complaints

Members have the right to submit complaints to HPSM. A complaint is any verbal or written expression of dissatisfaction with any HPSM covered service a member receives. A complaint may also be about reimbursement for a bill that a member has paid. A complaint can be a grievance or an appeal.

Grievance

A complaint expressing dissatisfaction with any aspect of HPSM’s or a provider’s operations, activities, or behaviors, including quality of care concerns, regardless of whether any remedial action is requested or can be taken. Examples of grievances include member concerns about:

  • Quality of the care that was provided.
  • Customer service that was perceived as rude or unhelpful.
  • Difficulty accessing care and/or the timeliness of care.
  • Billing related issues such as receipt of a balance bill or collections notice.
  • Other issues, such as HIPAA violations or potential instances of fraud.

Member grievances related to Medi-Cal pharmacy services provided or requested in 2022 will no longer be handled by HPSM and instead will be handled by Magellan. Members can submit a grievance either in writing or by telephone by going to www.Medi-CalRx.dhcs.ca.gov or calling Magellan Customer Service at 1-800- 977-2273.

Appeal

A complaint about HPSM’s denial of coverage or reimbursement. In an appeal, a member or provider requests HPSM to reconsider its decision regarding services that were denied, limited, or taken away, such as:

  • A denied request for services (i.e., prior authorization).
  • A denied request for payment to a provider (i.e., claim).
  • A denied request for reimbursement to a member.

Member appeals related to Medi-Cal pharmacy services provided or requested in 2022 will no longer be handled by HPSM and instead will be handled through the State Fair Hearing Process (see “State Fairing Hearing for Medi-Cal Members” section for additional details.

Timeframes in the Member Complaint Process

The following are the timeframes that must be followed when processing a grievance and/or an appeal. Timeframes for filing a grievance or appeal vary by line of business and are regulated by CMS and the state.

Timeframes for CareAdvantage Cal MediConnect

For filing

TypeTimeframe
Part C Appeal:60 calendar days from denial notice
Part D Appeal:60 calendar days from denial notice
All Grievances:No time limit

For processing

TypeAppealGrievance
Part C Standard30 calendar days (seven days for Part B drug requests)30 calendar days
Part C Expedited72 hours (24 hours for Part B drug requests)24 hours
Part D Standard7 calendar days30 calendar days
Part D Expedited72 hours24 hours

Timeframes for Medi-Cal

For filing non-pharmacy grievances & appeals (through HPSM)

TypeTimeframe
All Appeals:60 calendar days from denial notice
All Grievances:No time limit

For processing non-pharmacy grievances & appeals (through HPSM)

TypeTimeframe
Standard 30 calendar days
Expedited72 hours

For filing pharmacy grievances & appeals (through Magellan)

TypeTimeframe
All appeals120 calendar days from denial notice
All grievancesNo time limit

For processing pharmacy grievances & appeals (through Magellan)

TypeAppealsGrievances
Standard90 calendar days30 business days
Expedited3 calendar days30 business days

Timeframes for HealthWorx HMO and ACE

For filing

TypeTimeframe
All appeals180 calendar days from denial
All grievances180 calendar days from incident

For processing

TypeAppealsGrievances
Standard30 calendar days30 calendar days
Expedited72 hours72 hours

Member Grievances

Members may submit a grievance to HPSM if they are dissatisfied with any aspect of HPSM’s or a provider’s operations, activities, or behaviors. Please note that the grievance procedures for members receiving Medicare benefits under HPSM CareAdvantage differ slightly from procedures for members receiving benefits under HPSM’s other lines of business. These differences are clearly indicated throughout this section.

Filing a Grievance

Member grievances for all services can be submitted through the following routes:

In-person*

Health Plan of San Mateo
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

*For the safety all HPSM members and employees, and to comply with public health guidelines, HPSM will no longer host in-person meetings at our offices during the COVID-19 pandemic. However, HPSM is committed to serving your needs during this crisis.

Phone

Medi-Cal, HealthWorx and ACE members can call Member Services at 650-616-2133

CareAdvantage members can call the CareAdvantage Unit at 650-616-2174

Fax

Fax: 650-829-2002

Mail

Health Plan of San Mateo
Attn: Grievance and Appeals
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Filing a Grievance for Medi-Cal Pharmacy Benefits

Member Grievances for Medi-Cal pharmacy benefits are handled by Magellan be and can be submitted through the following routes:

Phone

Call Magellan Customer Service Center at 800-977-2273 or log onto www.medi-calrx.dhcs.ca.gov to securely email a complaint

Fax

Fax the Medi-Cal Rx Complaint Form (available at medi-calrx.dhcs.ca.gov/home/ to Medi-Cal Customer Service Center at 1-800-869-4325

Mail

Mail the Medi-Cal Rx Complaint Form (available at medi-calrx.dhcs.ca.gov/home/ to the following:

Medi-Cal Rx Customer Service Center
Attn: Complaints and Grievances Unit
P.O. Box 730
Rancho Cordova, California 95741-0730

Timing

Medi-Cal members may file a grievance at any time regarding services they received while covered under Medi-Cal.

CareAdvantage Cal MediConnect members may file a grievance within 60 days from the date of occurrence while covered CareAdvantage Cal MediConnect.

All other members must file a grievance within 180 calendar days from the date of occurrence. HPSM may allow an exception to this timeframe requirement for good cause.

How to Submit a Grievance

If filing a grievance in writing, members may submit a grievance online at www.hpsm.org.Members may also fill out a grievance form, found on HPSM's website, or write a letter or other statement stating the reason for their dissatisfaction. Members can also submit grievances through provider offices. Providers are required to send these to HPSM on the same business day that the grievance was received. Providers will send this information to HPSM via fax at 650-829-2002.

Member grievances may be received by HPSM’s Member Services Unit, the CareAdvantage Unit, Care Coordination/Integrated Care Management Unit, or Grievance and Appeals Unit. If a grievance is received by Member Services or CareAdvantage Unit, staff will make every effort to resolve the grievance within 24 hours.

Providers may submit grievances against members, HPSM and/or other providers by contacting HPSM’s Provider Services Department at PSInquiries@hpsm.org.

Providers can also submit Potential Quality Issues (PQIs) using the HPSM PQI Referral Form.

If the grievance cannot be resolved in 24 hours, the complaint will be forwarded to Grievance and Appeals for further processing.

For grievances related to Medi-Cal pharmacy services: Complaints or grievances may be filed by a member, a member’s authorized representative, or other interested party (e.g., an anonymous submitter, or a provider acting on behalf of the member). Complaints or grievances for Medi-Cal pharmacy services provided or requested in 2022 can be filed at any time and may be submitted in person, in writing (e.g., mail, email, or chat), or by phone.

For more information on how to file a pharmacy related grievance, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

Canceling/Withdrawing a Grievance

Members or their authorized representatives may cancel their grievance at any time by contacting HPSM’s Grievance and Appeals Unit.

To cancel grievances for Medi-Cal pharmacy services handled by Magellan, please call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

Processing and Resolving Standard Grievances

Once a grievance is filed, a Grievance and Appeals Coordinator will send an acknowledgment letter to the member within five calendar days. The Grievance and Appeals Coordinator will investigate the grievance, which may include notifying the member’s provider, if applicable.

For grievances related to Medi-Cal pharmacy services, Magellan will automatically send an acknowledgement letter to the member within one business day if their Customer Service Center cannot fully resolve the grievance immediately.

Provider Response and Timing

A critical part of resolving a member complaint involves getting a provider’s perspective about the situation under review. Requests for a provider’s perspective are not an accusation of wrongdoing. HPSM understands that many complaints arise because of a difference in perception or misunderstanding about a situation. We want to get your honest opinion about what transpired.

To meet the strict timeframes for processing a complaint, providers must submit their response within five calendar days from the date the Grievance and Appeals Coordinator sends the request to the provider.

For grievances related to Medi-Cal pharmacy services filed by a member, Magellan may contract a prescriber for addition information. Providers should respond to any inquiries from Magellan or DHCS to expedite processing timeframes for a grievance.

Resolving a Grievance

For standard complaints, the Grievance and Appeals Coordinator will issue a resolution letter within 30 calendar days of receipt of the grievance. The resolution letter will be the result of the research and review conducted by the Grievance and Appeals Coordinator. The resolution letter will be mailed to the member or the member’s representative. If the grievance involves a provider, a copy of the resolution letter will also be sent to the provider.

If a grievance is related to quality-of-care concerns, HPSM will request medical records and a written response from all relevant providers. These medical records and responses will be reviewed by HPSM’s Clinical Review Nurse and by an HPSM Medical Director. Providers will be informed in writing of any concerns or deficiencies found by HPSM’s Quality Improvement Department. For questions regarding the quality-of-care review process, please contact the Quality Department at 650-616-2170.

For grievances related to Medi-Cal pharmacy services, Magellan will usually issue a resolution letter within 30 business days of receipt of the grievance.

Non-Retaliation Policy for Filing a Grievance

Members have the right to file a complaint about HPSM or the care that they receive from a provider without the complaint adversely affecting how the member is treated by HPSM and/or the member’s providers. Retaliation against members for filing a complaint is strictly prohibited.

HPSM does not discriminate against or disenroll members for filing complaints.

Examples of prohibited retaliation by providers include:

  • Terminating or threatening to terminate a member from your practice after the member has filed a complaint.
  • Refusing to provide treatment or needed prescription refills to a member because of a complaint filed.
  • Treating the member in a disrespectful, hostile, or otherwise negative manner in response to the member filing a complaint.

Grievance to the Department of Managed Health Care

Members can call DMHC at 888-466-2219 or complete an Independent Medical Review/Complaint Form online, which can be accessed at www.dmhc.ca.gov/FileaComplaint.aspx.

HPSM will abide by the decision made by DMHC and will work to complete the actions recommended by DMHC as quickly as possible.

All grievances related to Medi-Cal pharmacy services should not be submitted to DMHC and instead should be submitted to Magellan.

Mediation

Prior to filing a grievance with the Department of Managed Health Care, a member may request voluntary mediation with HPSM. A member does not have to participate in voluntary mediation for longer than 30 days before being able to submit a grievance to the Department of Managed Health Care. Expenses for mediation are paid for equally by HPSM and the member.

This does not apply to grievances related to Medi-Cal pharmacy services which must be submitted to Magellan.

Expedited Grievances

For Medi-Cal, HealthWorx, and ACE members

If processing a grievance under the standard 30 calendar day timeframe would have an adverse impact on a member’s life, health, or ability to regain maximum function, a member or provider can request that a grievance be processed under an expedited, 72 hour timeframe. If a member, a physician, or other provider request expedited grievance processing, HPSM clinical staff will determine whether the request meets the criteria for expedited processing. If the request does not meet the criteria for expedited processing, the HPSM Grievance and Appeals Unit will notify the member or the requestor of this decision verbally, and in writing.

There is no expedited process for grievances related to Medi-Cal pharmacy services and all processing timeframes are usually resolved within 30 days.

For CareAdvantage Cal MediConnect members

CareAdvantage members have the option of requesting an expedited grievance under limited circumstances. Unlike the other lines of business, the decision to expedite processing of a CareAdvantage grievance is not based on clinical criteria. The circumstances in which an expedited grievance may be filed by or for a CareAdvantage member are:

  • HPSM refused to expedite an authorization request.
  • HPSM extended the timeframe to process an authorization request.
  • HPSM refused to expedite an appeal.
  • HPSM extended the timeframe to process an appeal.

In these cases, CareAdvantage members may request an expedited grievance. The Grievance and Appeals Coordinator will consult with the appropriate HPSM staff and respond to the grievance within 24 of HPSM’s receipt of the expedited grievance.

Appeals

Denied Services/Authorization Requests

Any member who is denied services may request an appeal of this decision if they disagree with the denial reason. As an HPSM contracted provider, you may file an appeal on behalf of a HPSM member, but you cannot charge the member for filing an appeal on their behalf. An authorized representative of the member may also file an appeal.

Provider Payment Appeals

For providers disputing payment, please refer to the Provider Dispute Resolution Process described in “Section 5: Provider Disputes” of this manual.

Pharmacy Appeals

For pharmacy providers disputing payment of Medi-Cal pharmacy services (e.g., resubmission, nonpayment, underpayment, overpayment, etc.) provided or requested in 2021 for Medi-Cal members, providers should complete the Medi-Cal Rx Provider Appeal form and submit the completed form to:

Medi-Cal CSC
Attn: Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, California, 95741-0610

Authorization Appeals

You may ask HPSM to reconsider a denial of an authorization request for services if you or your patient disagree with HPSM’s decision to deny the request. You may also be called upon to assist a member or authorized representative if he/she requests an appeal, or to forward relevant medical records to help us decide on an appeal.

For CareAdvantage Members

If you are a physician and you appeal the decision on behalf of a member, the member will not need to submit documentation designating you as the member’s authorized representative. However, if you are a provider other than a physician (e.g. DME provider, SNF, physical therapist, etc.), the member will need to provide documentation designating you as the member’s authorized representative.

Providers can file appeals through the following routes:

Phone

Call 650-616-2850

Fax

Fax 650-829-2002

Mail

Health Plan of San Mateo
Attn: Grievances and Appeals
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Members can file appeals through the following routes:

In-person*

Health Plan of San Mateo
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

*For the safety all HPSM members and employees, and to comply with public health guidelines, HPSM will no longer host in-person meetings at our offices during the COVID-19 pandemic. However, HPSM is committed to serving your needs during this crisis.

Phone

Medi-Cal, HealthWorx and ACE members can call Member Services at 650-616-2133

CareAdvantage members can call the CareAdvantage Unit at 650-616-2174

Fax

Fax: 650-829-2002

Mail

Health Plan of San Mateo
Attn: Grievance and Appeals
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Appeals may be received by HPSM’s Member Services Department, Care Coordination/Integrated Care Management or by a Grievance and Appeals Coordinator.

Timing

For Medi-Cal and CareAdvantage Cal MediConnect members

For Medi-Cal and CareAdvantage Cal MediConnect members, an appeal must be filed within 60 calendar days from the date of HPSM's Notice of Denial. All other members must file an appeal within 180 calendar days of this date. HPSM may allow an exception to this timeframe requirement for good cause.

Cancelling/Withdrawing an Appeal

Members or their authorized representatives may cancel their request for an appeal at any time by contacting HPSM’s Grievance and Appeals Unit.

Processing a Standard Appeal

Once the appeal is filed, a Grievance and Appeals Coordinator will send an acknowledgment letter to the member within 5 calendar days and work with the appropriate HPSM staff to begin investigation of the case. Additional information for the service may be required from providers involved in the member’s treatment. Providers should provide this information within 5 calendar days of the request.

After all relevant documentation is collected, the case is forwarded to an HPSM Medical Director for review. The Medical Director that made the initial decision to deny the authorization request will not be involved in the appeal process.

Using all available information, the HPSM Medical Director will decide on the appeal request. HPSM will notify the provider and the member within 30 calendar days of the initial request. HPSM will call both the member and the provider to inform them of the appeal decision. The member and provider will also receive a letter confirming the decision.

For all appeals HPSM may extend the timeframe for up to 14 calendar days if requested, or if such extension is in the best interest of the member.

Requesting an Expedited Appeal

You may request an expedited appeal of an HPSM authorization denial if you or the member believes that applying the standard 30 calendar day timeframe for processing an appeal will jeopardize the member’s life, health, or ability to regain maximum function. HPSM will also expedite an appeal for decisions regarding termination or changes in level of care for inpatient stays, skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities.

CareAdvantage requests for expedited appeals that are submitted by telephone during non-business hours are received by HPSM’s answering service. The answering service will immediately page an HPSM Medical Director to provide expedited review.

Requests submitted by fax during non-business hours will be processed the following business day. If you are submitting an expedited appeal on a weekend or holiday, please do not submit the request by fax.

CareAdvantage requests for expedited review that have the support of a physician will automatically be approved.

In addition to HPSM’s expedited appeals process, Medi-Cal, and HealthWorx members can also contact the California Department of Managed Health Care (DMHC) and request an urgent review. Members do not need to go through HPSM’s expedited appeals process before contacting the DMHC. Requests for urgent review by the Department of Managed Health Care can be submitted by calling 888-466-2219.

Processing an Expedited Appeal

Upon receiving the request for an expedited appeal, a Grievance and Appeals staff member will confer with HPSM clinical staff to determine if the request meets the clinical criteria for an expedited review. This decision will be made within 24 hours of receipt of the request.

If the appeal does not qualify for an expedited review, a Grievance and Appeals staff member will immediately notify you and the member of this decision and any Grievance and Appeal rights, including the right to contact the DMHC. The case will then be reviewed through the standard appeals process.

If the appeal qualifies for expedited review, a Grievance and Appeals staff member will immediately notify you and the member of the decision and of the member’s right to contact the DMHC. He/she will work with the appropriate HPSM staff to collect all relevant information about the member’s condition and forward the case file to an HPSM Medical Director for review within 48 hours of receiving the request.

Using all available information, HPSM will decide and notify you and the member as expeditiously as the member’s health requires, but no later than 72 hours of HPSM’s receipt of the request. HPSM will notify you and the member of the decision by phone and in writing. If the original denial is upheld, HPSM’s written notification will include the reason for denial and information about additional levels of appeal that may be available.

Denials of CareAdvantage Part C Benefits

If a denial is upheld on appeal, HPSM will auto-forward the appeal to the Independent Review Entity (IRE) for a secondary, independent review. The IRE will render a decision within 30 days of receiving the appeal from HPSM. HPSM will comply with the decision by the IRE and notify the member and provider if the IRE instructs HPSM to overturn the denial, in full or in part.

For all appeals HPSM may extend the timeframe for up to 14 calendar days if requested, or if such extension is in the best interest of the member.

Independent Medical Review (IMR) For Medi-Cal and HealthWorx

If you or your patient disagrees with a decision HPSM has made on an appeal based on medical necessity, or if HPSM does not decide within the standard 30 calendar day timeframe, the member can request an Independent Medical Review (IMR) by the Department of Managed Health Care (DMHC).

An IMR may also be requested if HPSM denies a treatment because it is experimental or investigational; in this case, the member does not need to complete HPSM’s appeals process before requesting an IMR.

Information on requesting an IMR can be obtained by calling 888-466-2219, or by visiting the DMHC website at www.dmhc.ca.gov/FileaComplaint/FrequentlyAskedQuestions.aspx.

Note: A Medi-Cal member who has already participated in a State Hearing (see below) is not eligible to receive an IMR from the DMHC.

The IMR will review the case to determine whether the care requested is medically necessary. DMHC will render a decision on an IMR within 30 days of DMHC’s receipt of the IMR application for standard appeals, or within 3 business days for expedited appeals.

If the IMR determines that the service is medically necessary, HPSM will approve the requested service or make a payment within 5 business days.

State Hearing (Medi-Cal Members Only)

Medi-Cal members or their authorized representatives have the option of filing a state hearing with the Department of Social Services if they disagree with HPSM’s decision regarding denial of a requested service. A State Hearing is an appeal with an Administrative Law Judge from the Department of Social Services. Expedited State Hearings may also be requested.

Requests for State Hearings can be submitted by:

Phone

Call 1-800-952-5253

Fax

Fax 916-651-5210 or 916-651-2789

In-writing

California Department of Social Services
Attn: State Hearing Division
Post Office Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

Online

www.dss.cahwnet.gov/shd/PG1110.htm

A Medi-Cal member must first exhaust HPSM's appeals process prior to proceeding with a State Hearing. Requests for State Hearings must be submitted within 120 calendar days of an action with which the member is dissatisfied. For standard State Hearings, the State will decide within 90 days of the request. For expedited State Hearings, the State will decide within 72 hours.

Fast-Track Appeals to a Quality Improvement Organization (CareAdvantage CMC Members Only)

If a member disagrees with HPSM’s decision to terminate or change the level of care for services received in an inpatient stay, skilled nursing facility (SNF), home health agency (HHA), or a comprehensive outpatient rehabilitation facility (CORF), he/she may appeal the decision to the Quality Improvement Organization (QIO) which the Medicare program has contracted. In California, the QIO is Livanta.

Members are notified of their right to submit this appeal to the QIO when they receive their Notice of Discharge and Medicare Appeal Rights for inpatient stays, their Notice of Medicare Non-Coverage for SNF, CORF, or HHA terminations, or other notice of non-coverage.

Members must request an appeal by noon of the first business day following receipt of the notice to avoid financial liability during the contested time. The QIO will decide within 24 hours. If the member misses the deadline for a QIO fast-track appeal, he/she may still request an expedited appeal from HPSM.

Pharmacy Appeals for Drug/Medication Denials

For Medi-Cal

For providers who wish to appeal a denied decision related to Medi-Cal pharmacy services provided or requested in 2022, an appeal must be submitted to Magellan. For more information regarding the appeal submission process and time frames, please visit the Medi-Cal Rx website at medicalrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

For Medi-Cal members or their authorized representatives who wish to file an appeal for pharmacy services provided or requested in 2022, they must do so through the State Fair Hearing process. Appeals must be submitted within 90 days from the denial notification.

For CareAdvantage, HealthWorx, and ACE

Appeals for medications or drugs are processed by HPSMʼs Pharmacy Services. Although the appeal process is similar, the timelines for prescription drug appeals differ:

  • For CareAdvantage: Pharmacy appeals must be submitted within 60 calendar days from the denial notification. HPSM will decide and will notify the member and provider within 7 calendar days for standard appeals and within 72 hours for expedited appeals.
  • For HealthWorx and ACE: Pharmacy appeals must be submitted within 180 days from the denial notification. HPSM will decide and will notify the member and provider within 30 calendar days for standard appeals and within 72 hours for expedited appeals.

Filing a Pharmacy Appeal

Medi-Cal

Mail

Providers can appeal Medi-Cal Rx prior authorization denials, delays, and modifications. Providers should submit appeals of prior authorization adjudication results, clearly identified as appeals, to:

Medi-Cal CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, California 95741-0610

Medi-Cal Rx will acknowledge each submitted PA appeal within three days of receipt and make a decision within 60 days of receipt. Medi-Cal Rx will send a letter of explanation in response to each PA appeal. Providers who are dissatisfied with the decision may submit subsequent appeals. Medi-Cal providers may seek a judicial review of the appeal decision, as authorized under state law. For more information about the Medi-Cal Rx provider PA appeal process, please visit the Medi-Cal Rx website.

CareAdvantage, HealthWorx, and ACE

Phone

Call 650-616-2088

Fax

Fax 650-829-2045

Mail

Health Plan of San Mateo
Attn: Pharmacy Unit
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Members can file pharmacy appeals through the following routes:

Medi-Cal (through the State Hearing Process)

Phone

Call 1-800-743-8525 or 1-800-952-5253

TDD 1-800-952-8349

Fax

Fax 833-281-0905. (Complete the “Request for State Hearing” form on the back of the Notice of Action)

Mail

California Department of Social Services
State Hearing Division
Post Office Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

(Complete the “Request for State Hearing” form on the back of the Notice of Action)

Online

Visit acms.dss.ca.gov/acms/login.request.do

CareAdvantage, HealthWorx, and ACE

Phone

CareAdvantage members call 650-616-2174

Healthworx and ACE members call 650-616-2133

Fax

Fax 650-829-2045

In-person* or by mail

Health Plan of San Mateo
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

External Appeals for CareAdvantage Members Only

HPSM CareAdvantage members have access to successive levels of appeal to contest adverse denials and appeals. These include:

  • Review by an Independent Review Entity (IRE)
  • Administrative Law Judge (ALJ) hearing
  • Medicare Appeals Council (MAC) hearing
  • Judicial Review

Independent Review Entity (IRE)

If HPSM upholds its original denial, a member, authorized representative, or physician may request external review by the IRE. Unlike appeals for Part C benefits, appeals for Part D covered drugs will not be automatically forwarded to the IRE for review. To file a second-level appeal with the IRE, the provider or member should fill out the form attached to the written notification from HPSM.

For a Part D appeal denial to be reviewed by the IRE, the member must submit a written request to the IRE within 60 days of the date of the appeal denial decision. In this case, the IRE is required to solicit the prescribing physician’s views on the case.

The IRE will decide on the case within the same timeframes as HPSM:

  • 7 days for a Part D appeal.
  • 30 days for a standard Part C pre-service authorization appeal (7 days for Part B drug).
  • 60 days for a Part C payment appeal.
  • 72 hours for an expedited Part D or Part C pre-service authorization appeal.

If the IRE overturns HPSM’s decision, HPSM will authorize and/or provide service or payment within the following timeframes:

  • 72 hours for a standard Part D appeal.
  • 24 hours for an expedited Part D appeal.
  • 14 calendar days for a standard Part C pre-service authorization.
  • 72 hours for an expedited Part C pre-service authorization.
  • 30 calendar days for a standard Part C payment appeal.

Administrative Law Judge Hearing

In cases where the denied service being contested has met minimal dollar amount standards (set annually), the member, provider, or authorized representative can request a hearing before an Administrative Law Judge (ALJ). This request must be made within 60 calendar days of receiving unfavorable notice by the IRE and should be submitted to the Social Security Administration or the IRE. Upon request, HPSM can also forward members’ requests for an ALJ hearing to the IRE.

If the ALJ overturns HPSM’s decision, the following timeframes will apply:

  • 72 hours to authorize and/or provide service for pre-service Part D appeals.
  • 72 hours to authorize payment for Part D appeals and 30 days to issue payment.
  • 60 calendar days to authorize and/or provide service or payment for Part C appeals.

HPSM may request a review by the Medicare Appeals Council (MAC), in which case HPSM may wait for the MAC’s decision before authorizing service or payment.

Medicare Appeals Council (MAC)

Any party to an appeal, including a member, provider, authorized representative, or HPSM, can request a hearing before the Medicare Appeals Council (MAC). This request must be made within 60 calendar days of receiving notice by the ALJ and should be submitted in writing to the MAC. Upon request, HPSM can also forward members’ requests for a MAC review.

If the MAC overturns HPSM’s decision, the same timeframes for acting upon the decision as are required for ALJ decisions will apply.

Judicial Review

Any party to an appeal, including a member, provider, authorized representative, or HPSM, can request judicial review of a MAC decision if: (1) the MAC denied the request for a review, and (2) the amount of the service in question meets the minimal dollar amount set annually. To request judicial review, the party must file a civil action in a U.S. District Court.

If judicial review overturns HPSM’s decision, the same timeframes for acting upon the decision as are required for ALJ and MAC decisions will apply.

Submit a grievance in writing

If filing a grievance in writing, members may submit a grievance online at HPSM's website, www.hpsm.org. Members may also fill out a Grievance Form, found on HPSM's website, or write a letter or other statement stating the reason for their dissatisfaction. Members can also submit grievances through provider offices. Providers are required to send these to HPSM on the same business day that the grievance was received. Providers will send this information to HPSM via Fax at 650-829-2002.

Member grievances may be received by HPSM’s Member Services Unit, the CareAdvantage Unit, Care Coordination Unit, or Grievance and Appeals Unit. If a grievance is received by Member Services or CareAdvantage Unit, staff will make every effort to resolve the grievance within 24 hours.

Providers may submit grievances against members, HPSM and/or other providers by contacting HPSM’s Provider Services Department at PSInquiries@hpsm.org.

Providers can also submit Potential Quality Issues (PQIs) using the Potential Quality Issue Referral Form.

If the grievance cannot be resolved in 24 hours, the complaint will be forwarded to Grievance and Appeals for further processing.

Canceling/withdrawing a grievance

Members or their authorized representatives may cancel their grievance at any time by contacting HPSM’s Grievance and Appeals Unit.

Standard Grievance Process

Once a grievance is filed, a Grievance and Appeals Coordinator will send an acknowledgment letter to the member within five calendar days. The Grievance and Appeals Coordinator will investigate the grievance, which may include notifying the member’s provider, if applicable.

Provider response

A critical part of resolving a member complaint involves getting a provider’s perspective about the situation under review. Requests for a provider’s perspective are not an accusation of wrongdoing. HPSM understands that many complaints arise because of a difference in perception or misunderstanding about a situation. We want to get your honest opinion about what transpired.

To meet the strict timeframes for processing a complaint, providers must submit their response within five (5) calendar days from the date the Grievance and Appeals Coordinator sends the request to the provider.

Resolving a grievance

For standard complaints, the Grievance and Appeals Coordinator will issue a resolution letter within 30 calendar days of receipt of the grievance. The resolution letter will be the result of the research and review conducted by the Grievance and Appeals Coordinator. The resolution letter will be mailed to the member or the member’s representative. If the grievance involves a provider, a copy of the resolution letter will also be sent to the provider.

If a grievance is related to quality of care concerns, HPSM will request medical records and a written response from all relevant providers. These medical records and responses will be reviewed by HPSM’s Clinical Review Nurse and by an HPSM Medical Director. Providers will be informed in writing of any concerns or deficiencies found by HPSM’s Quality Improvement Department. For questions regarding the quality of care review process, please contact the Quality Department at 650-616-2170.

Non-retaliation policy for filing a grievance

Members have the right to file a complaint about HPSM or the care that they receive from a provider without the complaint adversely affecting how the member is treated by HPSM and/or the member’s providers. Retaliation against members for filing a complaint is strictly prohibited.

HPSM does not discriminate against or disenroll members for filing complaints.

Examples of prohibited retaliation by providers include:

  • Terminating or threatening to terminate a member from your practice after the member has filed a complaint.
  • Refusing to provide treatment or needed prescription refills to a member because of a complaint filed.
  • Treating the member in a disrespectful, hostile, or otherwise negative manner in response to the member filing a complaint.

Grievances submitted to the DMHC

Members in Medi-Cal and HealthWorx may submit grievances related to all services to the Department of Managed Health Care (DMHC) under the following conditions:

  1. They disagree with the decision made by HPSM.
  2. HPSM has not resolved their grievance within the 30 calendar day timeframe

Members can call the DMHC at 888-466-2219 or complete an Independent Medical Review/Complaint Form at www.dmhc.ca.gov/FileaComplaint.aspx.

HPSM will abide by the decision made by DMHC and will work to complete the actions recommended by the DMHC as quickly as possible.

Prior to filing a grievance with the DMHC, a member may request voluntary mediation with HPSM. A member does not have to participate in voluntary mediation for longer than 30 days before being able to submit a grievance to the DMHC. Expenses for mediation are paid for equally by HPSM and the member.

Expedited Grievances

Medi-Cal, HealthWorx, and ACE Participants

If processing a grievance under the standard 30 calendar day timeframe would have an adverse impact on a member’s life, health, or ability to regain maximum function, a member or provider can request that a grievance be processed under an expedited, 72 hour timeframe. If a member, a physician, or other provider requests expedited grievance processing, HPSM clinical staff will determine whether the request meets the criteria for expedited processing. If the request does not meet the criteria for expedited processing, the HPSM Grievance and Appeals Unit will notify the member or the requestor of this decision verbally, and in writing.

CareAdvantage CMC Members

CareAdvantage members have the option of requesting an expedited grievance under limited circumstances. Unlike the other lines of business, the decision to expedite processing of a CareAdvantage grievance is not based on clinical criteria. The circumstances in which an expedited grievance may be filed by or for a CareAdvantage member are:

  • HPSM refused to expedite an authorization request
  • HPSM extended the timeframe to process an authorization request
  • HPSM refused to expedite an appeal
  • HPSM extended the timeframe to process an appeal

In these cases, CareAdvantage members may request an expedited grievance. The Grievance and Appeals Coordinator will consult with the appropriate HPSM staff and respond to the grievance within twenty-four (24) hours of HPSM’s receipt of the expedited grievance.

Appeals of Denied Services/Authorization Requests

Any member who is denied services may request an appeal of this decision if the disagree with the denial reason. As an HPSM contracted provider, you may file an appeal on behalf of a HPSM member, but you cannot charge the member for filing an appeal on their behalf. An authorized representative of the member may also file an appeal.

You may ask HPSM to reconsider a denial of an authorization request for services if you or your patient disagree with HPSM’s decision to deny the request. You may also be called upon to assist a member or authorized representative if he/she requests an appeal, or to forward relevant medical records to help us make a decision on an appeal.

For CareAdvantage Members: If you are a physician and you appeal the decision on behalf of a member, the member will not need to submit documentation designating you as the member’s authorized representative. However, if you are a provider other than a physician (e.g. DME provider, SNF, physical therapist, etc.), the member will need to provide documentation designating you as the member’s authorized representative.

 

 

End of Section 3: Member Complaints