Grievances

 

We take pride in being a Member-focused health plan.  Our Member Services Department is able to assist you in resolving your concerns by calling (888) 421-8444 (toll-free), Monday through Friday, 9:00 a.m. - 5:00 p.m.

We encourage our Members to contact us first to resolve any concerns they may have.  However, members wishing to file a Grievance about any aspect of the services provided by the Valley Health Plan (VHP) may do so by following the Grievance and Appeals process.

A Grievance can be filed on your behalf by a Member Services Advocate or you can complete a Grievance Form on your own and submit it to Valley Health Plan (VHP).  Grievance forms are available in three languages through VHP, at your provider's office, and by using the links on the bottom of the page. 

Send your Grievance to:

Valley Health Plan
Attention: Grievance Department
2480 N. First Street, Suite 160
San Jose, CA 95131

Please include the details and circumstances about your concern or problem along with information from your VHP ID card. Additional information can include copies of medical records or physician opinions in support of your Grievance.  Your medical records may need to be obtained from your Plan Physician or you may need to obtain them from a Non-Plan Physician.  Please provide as much information as possible in order to reduce the time required to collect such data. Your Grievance will be acknowledged within five (5) calendar days of receipt.

After the Grievance Review Committee makes its decision, VHP will notify you in writing of the outcome within thirty (30) calendar days of receiving your Grievance. If the Grievance involves an imminent and serious threat to your health or the health of your Dependents, including but not limited to, severe pain, psychological wellbeing, potential loss of life, limb, or major bodily function you will be entitled to an expedited review. The Grievance must state that you are requesting an expedited review. You will be notified of the outcome or status within three (3) working days of receipt of the Grievance.
 
DMHC Consumer Help-Line
If you are not satisfied with the decision of the Grievance Review Committee, you may contact the California State Department of Managed Health Care (DMHC).

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 (888) 421-8444 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 ((888) 466-2219) and a TDD line ((877) 688-9891) for the hearing and speech impaired. The department's internet website http://www.dmhc.ca.gov/ has complaint forms, IMR application forms, and instructions online.