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Grievances & Appeals

What is a Grievance?

A grievance is any written or oral expression of dissatisfaction made by you, your representative or your provider regarding your experience with WHA, your medical group or any WHA participating practitioner.

A “standard” or routine grievance is usually investigated and resolved within 30 calendar days. A “fast track” or expedited grievance is completed within 72 hours from receipt of the formal complaint.

What is an Appeal?

An appeal is a verbal or written formal request to re-review or reconsider a decision that has been made. The appeal can be related to a payment issue, an administrative action, quality of care or service issue or utilization recommendation. Your appeal will be reviewed by a doctor who was not involved in the initial review of the issue. This doctor will make an independent second decision after reviewing all available information. The second decision may agree or disagree with the first decision.

Standard or routine appeals are completed within 30 calendar days. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision. Expedited or “fast track” appeals are completed within 72 hours upon request if delaying the appeal decision risks jeopardizing your health. You have the right to request a “fast track” or expedited appeal if your doctor agrees there are health risks in delaying the decision. WHA’s Medical Director or appropriately licensed designee will make the decision if the appeal will be handled as an expedited or standard appeal.

What is WHA's Grievance and Appeal Procedure?

If you have a complaint with regard to WHA’s failure to authorize, provide or pay for a service that you believe is covered, a cancellation, termination, non-renewal or rescission of your membership or any other complaint, please call Member Services for assistance. If your complaint is not resolved to your satisfaction after working with a Member Services representative, a verbal or written grievance or appeal may be submitted to:

Mail: Western Health Advantage
  Attn: Grievance and Appeals
  2349 Gateway Oaks Drive, Suite 100
  Sacramento, CA 95833
Secure Fax: 916.563.2207
Call: WHA Member Services
  916.563.2250 or 888.563.2250
Secure Email: mywha.org/securemessage

 

You may also start the grievance process by completing WHA's online grievance form.

Please include a complete discussion of your questions or situation and your reasons for dissatisfaction and submit the grievance and appeal to WHA Member Services, Grievance and Appeals Department within one hundred eighty (180) days of the incident or action that caused your dissatisfaction. If you are unable to meet this period, please contact Member Services on how to proceed.

If you are appealing a denial of services included within an already-approved ongoing course of treatment, coverage for the approved services will be continued while the appeal is being decided.

If you believe that your membership has been or will be improperly canceled, rescinded or not renewed, you may request a review by the Department of Managed Health Care after participating in WHA’s grievance process for thirty (30) days. If your coverage is still in effect when you submit your grievance to WHA, your coverage will be continued while your grievance is being decided, including during the time it is being reviewed by the Department of Managed Health Care. All premiums must continue to be paid timely for coverage to continue. At the conclusion of the grievance, including any appeal to the Department of Managed Health Care, if the issue is decided in your favor, coverage will continue or you will be reinstated retroactively to the date your coverage was initially terminated. All premiums must be up to date and paid timely. To file a request for Termination Review, please call Member Services or complete and send this Request for Termination Review [Pedido de Revisión de Terminación] form to WHA

WHA sends an acknowledgment letter to the Member within five (5) calendar days of receipt of the Grievance or Appeal. A determination is rendered within thirty (30) calendar days of receipt of the Member’s Grievance or Appeal. WHA will notify the Member of the determination, in writing, within three (3) working days of the decision being rendered.

A grievance form and a description of the grievance procedures are available at every Medical Group and Plan facility. In addition, a grievance form will be promptly sent to you if you request one by calling Member Services. If you would like assistance in filing a grievance or an appeal, please call Member Services and a representative will assist you in completing the form or explain how to write your letter. We will also be happy to take the information over the phone verbally or through a secure message

It is the policy of WHA to resolve all  grievances and appeals within thirty (30) days of receipt. For appeals of denials of coverage or benefits, you will be given the opportunity to review the contents of the file and to submit testimony to be considered. Written notification of the disposition of the grievance or appeal will be sent to the Member and will include an explanation of the contractual or clinical rationale for the decision. Contact Member Services for more detailed information about the grievance and appeal procedure.

If you have a complaint about your dental, vision, chiropractic/acupuncture, or mental health services, contact our Plan partners for information regarding how to lodge a grievance or appeal.

We are currently enhancing the online renewal system. Please check back soon. For immediate assistance, contact a WHA Individual Plan Specialist at 888.563.2250 or individualsales@westernhealth.com.

This SBC is currently unavailable online.
For assistance, please contact WHA Sales as described below.

Call 888.563.2250 or email individualsales@westernhealth.com.

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