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Grievance Form Medi-Cal

The Alliance will acknowledge receipt of your complaint or appeal in writing within five (5) calendar days, and respond to your complaint or appeal in writing within thirty (30) calendar days.

Note: This form is for use by Alliance Medi-Cal members only. All fields are mandatory.

Fields with an asterisk (*) are required.

You can have a family member or a friend help you file your complaint.

The State Office of the Ombudsman will help Medi-Cal members who are having problems with their health plan. You can call them toll free at (888) 452-8609.

Your Right to Request a State Fair Hearing

If you have filed an appeal with the Alliance and received an appeal resolution letter, or if the Alliance did not resolve or respond to your appeal according to the timelines outlined above, you can ask for a State Hearing. You must ask for the hearing within 120 days from the date of receiving the Alliance’s appeal resolution letter.

You can call the California Department of Social Services (DSS) at 1(800) 952-5253 (TDD 1(800) 952-8349 for the hearing and speech impaired) and tell them that you want a hearing. You can also ask for a State Fair Hearing by mail, telephone, or in person by contacting the following office in the county where you live.

Human Services Department
1000 Emeline Street
P.O. Box 1320
Santa Cruz, CA 95061
(831) 454-4117

Monterey County Department of Social & Employment Services
Attention: Fair Hearings Officer
1000 S. Main Street, Suite 208
Salinas, CA 93901
831-755-4472
866-323-1953

Merced County Human Services Agency
Attention: Hearing Coordinator
2115 W. Wardrobe Avenue
Merced, CA 95341
(209) 385-3000

If you feel the Alliance or a health care provider has not respected your privacy, you have the right to file a complaint with the Department of Health and Human Services at any time by contacting:

Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington DC, 20201

Un miembro de su familia o una amistad puede ayudarle con su queja.

La Oficina Estatal del Mediador ayudará a los miembros de Medi-Cal que tienen problemas con su plan médico. Puede llamarlos sin cargos al (888) 452-8609

Su Derecho a Solicitar una Audiencia Estatal Imparcial

Si presentó una apelación con la Alianza y recibió una carta de resolución de la apelación, o si la Alianza no resolvió o respondió su apelación de acuerdo con los plazos que se mencionaron anteriormente, puede solicitar una Audiencia Estatal. Debe solicitar la audiencia durante 120 días a partir de la fecha en que haya recibido la carta de resolución de la apelación de la Alianza. Puede llamar al Departamento de Servicios Sociales de California (Department of Social Services; DSS, por sus siglas en inglés) al 1-800-952-5253 (TDD 1-800-952-8349) para las personas con dificultades de audición o del habla) y dígales que desea una audiencia. También puede solicitar una Audiencia Estatal Imparcial por correo, teléfono o en persona comunicándose con las oficinas siguientes en el condado en el que usted reside:

Human Services Department
1000 Emeline Street
P.O. Box 1320
Santa Cruz, CA 95061
(831) 454-4117

Monterey County Department of Social & Employment Services
Attention: Fair Hearings Officer
1000 S. Main Street, Suite 208
Salinas, CA 93901
831-755-4472
866-323-1953

Merced County Human Services Agency
Attention: Hearing Coordinator
2115 W. Wardrobe Avenue
Merced, CA 95341
(209) 385-3000

Usted tiene derecho de presentar una queja ante el Departamento de Salud y Servicios Humanos en cualquier momento si considera que su confidencialidad no ha sido respetada. Presente su queja comunicándose con:

Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington DC, 20201

Koj hais tau ib tus neeg nyob hauv koj tsev neeg lossis ib tus phoojywg pab koj qhia peb txoj koj qhov kev tsis txaus siab los tau thiab.

Lub State Office of the Ombudsman pab daws cov teebmeem txog kev khomob. Lub chaw ua haujlwm no yuav pab cov tswvcuab uas muaj teebmeem nrog lawv txoj kev npaj khomob. Hu dawb rau lawv ntawm (888) 452-8609.

Koj Txoj Cai Uas Koj Muaj los Thov rau ib qho Kev Mus Hais Kev Ncaj Ncees

Yog hais tias koj tau ua ib qho kev hais kev tsis txaus siab nrog lub Alliance thiab koj tau txais daim ntawv ceeb toom txog kev thov rov hais qhov kev tsis txaus siab, los yog lub Alliance tsis tau txiav txim lossis teb tuaj rau koj qhov kev thov rov hais kev tsis txaus siab raws li cov sijhawm sau saum toj, koj tuaj yeem thov rau ib qho Kev Mus Hais Kev Ncaj Nees. Koj yuav tsum thov rau ib qho kev mus hais kev ncaj ncees rau lub sijhawm uas tsis pub dhau 120 hnub txij hnub tim uas koj tau txais lub Alliance daim ntawv ceeb toom txog kev thov rov hais qhov kev tsis txaus siab. Koj tuaj yeem hu rau California Lub Tuam Tsev Muab Kev Pab Rau Cov Pej Xeem (California Department of Social Services; DSS, raws li sau hauv lus Askiv) ntawm 1-800-952-5253 (TDD 1-800-952-8349 rau cov neeg tsis hnov lus lossis hais lus tsis tau) los thov rau ib qho kev mus hais kev ncaj ncees. Koj kuj ua ntawv xa tuaj, hu ntawm xov tooj, lossis tuaj tim ntsej tim muag thaum koj tau hu rau lub chav haujlwm uas nyob hauv koj lub cheeb nroog los thov rau ib qho Kev Mus Hais Kev Ncaj Ncees.

Merced County Human Services Agency
Attention: Hearing Coordinator
2115 W. Wardrobe Avenue
Merced, CA 95341
(209) 385-3000

Yog koj pom tias lub Alliance lossis koj tus kws khomob tsis ceev koj tej ntaub ntawv khomob zoo, koj tseem sau tau ntawv mus hais kev tsis txaus siab ntawm: