Member Rights Concerning Grievances & Appeals

There may be times when members disagree with a decision that was made by WHA or a medical group about benefit coverage or non-payment of care/service. Members may also express concerns about an experience they had with some aspect of their care/service. In these instances, members, or their designated representative (who may be their physician acting on their behalf) have the right to file an appeal and/or a grievance. Members have this right to file an appeal and/or grievance up to 180 calendar days following any incident or action that is the subject of a member's dissatisfaction. The following paragraphs briefly describe WHA's grievance and appeal processes.

Member Grievance

WHA members or their designated representative can file a complaint (grievance) by any one of the following three methods:

• Contact Member Services via telephone, Fax, or secure e-mail via WHA's website
• Write a letter explaining their concerns.
• Submit an online request using WHA's GRIEVANCE FORM.

When members contact Member Services via the telephone with a complaint, and the complaint is not a coverage dispute or disputed health care service involving medical necessity or experimental or investigational treatment, many times the issue can be resolved the same day or by the next day. When this occurs, members will be orally notified of the resolution no later than the end of the next business day following receipt of the grievance.

When a complaint cannot be resolved the same day or by the end of the next business day, or the grievance is received in writing and involves any of the issues noted above, receipt and resolution of the grievance are communicated to the member in writing according to the following timelines:

Standard Grievance:

• Notification of Receipt: Members are notified of receipt of the grievance within 5 calendar days of WHA's receipt of the grievance.

• Notification of Resolution: Members are notified of the resolution of the grievance within 30 calendar days of WHA's receipt of the grievance.

• Additional Notification: Members are notified of their right to contact the Department of Managed Health Care (DMHC) if they disagree with WHA's resolution.

Expedited Grievance:

(involving an imminent and serious threat to the health of the member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function; review is expedited upon notification from the member, an authorized representative, or the treating physician):

• Notification: Members are notified of the pending status or disposition of the grievance within 3 calendar days of WHA's receipt of the grievance.

• Immediate Notification: Members are notified immediately of their right to contact the DMHC without participating in WHA's grievance process first.

Member Appeals:

Member appeals include those cases involving delay, modification or denial of services based on a determination in whole or in part that the service is not medically necessary or is not a covered benefit. Appeals are reviewed by someone other than the person who made the initial denial determination. In addition, medical necessity appeals are reviewed by a practitioner in the same or similar specialty as the requesting practitioner.

Member appeals are processed according to the following timelines:

• Standard Pre-service Appeals: Standard pre-service appeals are resolved and the member is notified of the determination within thirty (30) calendar days of receipt.

• Post-service Appeals: Post-service appeals are resolved and the member is notified of the determination within thirty (30) calendar days of receipt.

• Expedited Appeal (involving an imminent and serious threat to the health of the member, including, but not limited to severe pain, potential loss of life, limb or major bodily function; review is expedited upon notification from the member, an authorized representative, or the treating physician): Expedited appeals are resolved and the member is notified of the determination within 72 hours of receipt.

Member Appeals:

Members can file a grievance or ask for an independent medical review (IMR) by contacting the California Department of Managed Health Care (DMHC). The DMHC reviews the request at no cost to the member and determines if the request qualifies for investigation or an IMR. The final determination to either overturn or uphold a denial made by WHA or a medical group is binding and WHA and the medical group must abide by the determination.

Members can learn more about WHA's Grievance & Appeal processes and Independent Medical Review from their Combined Evidence of Coverage and Disclosure booklet, by contacting Member Services, or by logging onto "Personal Access" in the member section of the WHA website.

WHA contact information:

Member Services: (916) 563-2250 or (888) 563-2250 Monday-Friday, 8 a.m. - 5 p.m.
Address: 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833
Website: westernhealth.com

DMHC contact Information:

Telephone: (888) HMO-2219 or TTY (877) 688-9891.
Website:: www.hmohelp.ca.gov; includes downloadable complaint forms, IMR application forms and online instructions.