Grievance and appeals process

 

1. Members wishing to file a grievance about any aspect of the services provided by the Valley Health Plan (VHP) may do so by filing a grievance online at the Valley Health Plan website or using the Grievance Reporting Form available at all contracted providers.  If you need assistance in completing this form, please ask for assistance from a representative at the facility or contact the Plan’s Member Services Department at (888) 421-8444 (toll-free).
2. You may also file your grievance in person with the Plan’s Member Services Department located in the Plan office at 2480 N. First Street, Suite 200, San Jose, CA 95131.  Plan staff are also available to assist you by phone at (888) 421-8444 (toll-free).
3. Members may contact The Department of Managed Health Care (DMHC) during business hours from Monday to Friday, 8:00am to 6:00pm throughout the Grievance & Appeal Process. The DMHC is responsible for regulating health care service plans. The Department has a toll-free number, (888) 466-2219, to receive grievances regarding health plans. If you have a grievance against the health plan, you should contact the plan and use its grievance process.
4. The Plan assures members that there will be no discrimination against members because they file a grievance.
5. The Plan’s Member Services Manager will review your grievance and will try to resolve your concerns to your satisfaction.
6. If the Member Services Manager is unable to resolve your grievance to your satisfaction, your grievance will be referred to the Plan’s Grievance Committee.  The Member Services Manager will schedule a hearing with the Grievance Committee members to review your grievance.
7. You will receive a written notice of the disposition of the Grievance Committee within 30 calendar days from the date the grievance was originally received.  This response explains the decision, the reason for the resolution, the right to appeal the Grievance Committees decision and the right of the member to contact the DMHC. Grievances that by their nature require more expeditious resolutions will be resolved as necessary to protect the health and welfare of the member. An enrollee has the right to request an independent medical review (IMR) in cases where the enrollee believes that health care services have been improperly denied, modified, or delayed by the Plan, or by one of its contracting providers.
8. The Grievance Committee will make every effort to render a decision on your grievance at the time of the hearing.  If this is not possible, the Committee will take the grievance under advisement.
9. A copy of all correspondence and all records related to the grievance and hearing shall be maintained for possible review by any appropriately authorized regulatory body.
10. You or your health care provider can ask us to decide your request faster if it involves imminent and serious threat to your health including but not limited to severe pain, or potential loss of life, limb, or major body function. Reasons for filing a grievance or appeal that requires an expedited review include, but are not limited to:
    • You have not received a service or supply, and you believe your condition is medically urgent and requires that service or supply.
    • A service or supply that you were receiving has been discontinued, and you believe your condition is medically urgent.
    • A request to continue a course of treatment that is ending.
    • If you decide to file an expedited grievance or appeal with VHP, VHP’s Medical Director will decide if your case qualifies for an expedited review. If the grievance or appeal is expedited, VHP will Resolve your grievance or appeal and notify you of our decision verbally and in writing within 72 hours of receipt of your grievance or appeal.
11. 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."