File a Grievance or Appeal

If you are not happy with a provider or the provider’s office, it is best to talk to them first. Let someone in the office know what happened as soon as possible. Ask them for help with fixing the problem. TotalCare is here to help you, so please call us for assistance.

If you are not happy with your experience in a hospital or other facility, you can ask to speak with a nurse, social worker or patient advocate. Then, call TotalCare so that we can help you.

If you get a bill for services that should be covered by TotalCare, call the billing department number listed on the bill. Let them know you have TotalCare as your insurance and ask them to send a claim to us directly. Then, call us right away. Tell us the amount charged, the date of service and the reason for the bill so we can help.

There is no time limit to file a complaint, but we encourage you to file it soon after the problem happens. If TotalCare denied a service you asked for and you disagree with this decision, you can file an appeal. An appeal has a time limit and must be filed within 60 calendar days from the date of a decision.

There are many ways to file a grievance:

• By phone: Call Member Services. Give us your TotalCare ID number, your name and the reason for your complaint.
• By mail:
  1. Download or request a grievance form. If you are a TotalCare member, you can download and fill out the TotalCare Member Grievance and Appeal Form. You can also call Member Services and ask to have a form sent to you, or you can request one from your doctor’s office.
  2. Fill out the form.
  3. Mail it to:
     Grievance Unit
     1600 Green Hills Road, Suite 101
     Scotts Valley, CA 95066
• Online: Fill out an online Grievance Form.
• In-person: Visit our office to speak face-to-face with a representative about your grievance.
• Provider’s office: You may file a grievance directly through your provider’s office.

You can also have a family member or friend help you file your grievance. If you want to learn how to file a discrimination grievance, download our Nondiscrimination Notice. If you need help in your language, go to our Language Assistance page.

Within 5 days of getting your complaint, we will send you a letter to let you know we received it. A TotalCare staff member from our Grievance Unit will look into the problem. A Grievance staff member may contact you to ask for more details. Within 30 days, we will send you another letter that explains how we solved the problem. If you want to know about the status of an existing grievance, please call us to speak to a Grievance staff member.

If you feel TotalCare or a health care provider did 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

State Hearing

If you are not happy with the decision on any appeal about a benefit or services determination, you can file a State Hearing. A State Hearing is when a Medi-Cal member requests an administrative law judge (ALJ) from the California Department of Social Services (CDSS) to review the Alliance’s appeal decision.

TotalCare Grievance staff can help you file a State Hearing with CDSS. You can also file a State Hearing directly by using one of the following options:

• By phone: Call 800-743-8525 (TTY: 800-952-8349).
• By mail:
  California Department of Social Services
  State Hearings Division
  P.O. Box 944243, Mail Station 9-17-37
  Sacramento, CA 94244-2430
• Request a hearing online on the CDSS website.

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, Monday-Friday from 8 a.m. to 5 p.m.

You can ask for an expedited, or fast review, if you think that TotalCare denied you a requested service that could be an urgent or serious threat to your health or life. An urgent or serious threat means that you believe your life is at risk, you may lose a limb or major bodily function or will be experiencing severe pain. If your grievance qualifies, we will resolve it within 72 hours of receipt.