What should I do if I am unhappy with my service from a medical provider, IEHP, or dissatisfied with my coverage, including an adverse benefit determination?
An adverse benefit determination means a decision by IEHP to deny, reduce, terminate, or fail to
pay for all or part of a benefit that is based on:
- Rescission of coverage, even if it does not have an adverse effect on a particular benefit at that time; or
- Determination of an individual's eligibility to participate in this IEHP plan; or
- Determination that a benefit is not covered; or
- An exclusion or limitation of an otherwise covered benefit based on a pre-existing condition exclusion or a source-of-injury exclusion; or
- Determination that a benefit is Experimental, Investigational, or not Medically Necessary or appropriate.
If you are not happy, are having problems or have questions about the service or care given to
you, you can let your PCP know. Your PCP may be able to help you or answer your questions.
There are two ways to report and solve problems:
- A complaint (or grievance) is when you have a problem with IEHP or a provider, or with the health care or treatment you got from a provider.
- An appeal is when you don’t agree with IEHP’s decision to change your services or to not cover them.
You have the right to file grievances and appeals with IEHP to tell us about your problem. This
does not take away any of your legal rights and remedies. We will not discriminate or retaliate
against you for complaining to us. Letting us know about your problem will help us improve
care for all members. You should always contact IEHP first to let us know about your problem.
Call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711).
What is a grievance?
A grievance is an expression of dissatisfaction, or a complaint by a member. The grievance can
be made in writing or verbally. For grievances regarding cancellation, rescission or nonrenewal
of coverage you must file your grievance or appeal with IEHP within 180 calendar days of the
termination notice. For all other issues, you must file your grievance within 365 calendar days
following the date of the incident or action that caused your grievance. Some examples are
complaints about:
- The service or care your PCP or other providers give you
- The service or care your pharmacy gives you
- The service or care your hospital gives you
- The service or care IEHP gives you
How to File a Grievance
You have many ways to file a grievance. You can:
- Call IEHP at 1-855-433-IEHP (4347) (TTY 711), Monday-Friday, 8am-6pm. Give Your Member ID number, your name and the reason for your complaint.
- Call IEHP at 1-855-433-IEHP (4347) (TTY 711), Monday-Friday, 8am-6pm, and ask to have a form sent to you. When you get the form, fill it out. Be sure to include your name, Member ID number and the reason for your complaint. Tell us what happened and how we can help you.
- Mail the form to:
IEHP
Attention: Grievance and Appeals Department
P.O. Box 1800
Rancho Cucamonga, CA 91729
Your doctor’s office will also have complaint forms. You can also get complaint forms online:
visit the IEHP website at iehp.org.
You may also call the California Department of Managed Health Care (DMHC) toll-free at
1-888-466-2219.
IEHP can help you fill out the grievance form over the phone or in-person. If you need
interpreting services, we will work with you to make sure we can communicate with you in your
preferred language. For members with hearing or speech loss, you may call IEHP’s TTY phone
number for IEHP Member Services at 711.
Within five (5) calendar days of receiving your grievance, you will get a letter from IEHP saying
we have Your grievance and are working on it. For grievances regarding cancellation, rescission,
or nonrenewal, IEHP will acknowledge receipt within three (3) calendar days. Then, within 30
calendar days of receiving your grievance, IEHP will send you a letter to explain how the
grievance was resolved.
Filing a grievance does not affect your medical benefits. If you file a grievance, you may be able
to continue a medical service while the grievance is being resolved. To find out more about
continuing a medical service, call IEHP.
If you are not satisfied with efforts to solve a problem with IEHP or your Provider, before filing
an arbitration proceeding, you must first file a grievance or appeal against IEHP by calling IEHP
Member Services at 1-855-433-IEHP (4347) (TTY 711)] or by submitting a Member Grievance
Form to IEHP.
Refer to the “Grievance, Appeals, Independent Medical Review and Arbitration,” section of the EOC for more information.