News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, Subject: Member Grievance Forms
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1 I M P O R T A N T News Flash! A FAX Publication for Providers of Sharp Health Plan To: From: Primary & Specialty Care Providers Sharp Health Plan Date: February 17, 2012 Subject: Member Grievance Forms The California Code of Regulations (Section (b)(7)) applies to all health care service plans and states: Grievance forms and a description of the grievance procedure shall be readily available at each facility of the plan, on the plan's website, and from each contracting provider's office or facility. Grievance forms shall be provided promptly upon request. As a contracting provider, you are required to provide a copy of the Sharp Health Plan (SHP) Grievance Form to any member/patient who requests it. To assist you with meeting this requirement, we have attached copies of the SHP Grievance Forms. Please keep these forms on hand should a member/patient ask for one when they are in the office. If you need additional copies of the Grievance Form, they can be found on our website at: in the Forms section. They are also available by contacting SHP at (619) or by ing provider.relations@sharp.com. If you would like additional information regarding the Sharp Health Plan Grievance process related to your office, please contact SHP Network Dev/Provider Support at (619) or (619)
2 MEMBER GRIEVANCE / APPEAL FORM MAIL OR FAX YOUR COMPLETED FORM TO: 4305 University Avenue, Suite 200 San Diego, CA FAX (619) If you believe this case involves an emergency, call Sharp Health Plan immediately at (619) or toll-free at (800) Member Information Name (Last, First, Middle Initial) Member Plan ID Number Mailing Address (Street, City, State, Zip) Daytime Area Code/Telephone Number Evening Area Code/Telephone Number Patient Information (If Patient is different than Member) Name (Last, First, Middle Initial) Member Plan ID Number Mailing Address (Street, City, State, Zip) Daytime Area Code/Telephone Number Evening Area Code/Telephone Number Provider Information (If applicable) Doctor/Provider/Medical Group Name Area Code/Telephone Number Address (Street, City, State, Zip) G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (English).doc
3 Instructions: Briefly outline the specific details of the problem and identify when the event(s) occurred. PLEASE BE SPECIFIC. Please include a statement regarding the outcome desired and what you believe the Plan can do to resolve your concern. If you have copies of documents, bills, checks, or other correspondence related to this problem that may help in the investigation and resolution, please include them with this form. If you need more pages to describe the issue, please attach them to this form. Member / Patient Signature I certify that this information is true and correct Date The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The department s Internet Web site has complaint forms, IMR application forms, and instructions online. G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (English).doc Page 2 of 2
4 FORMULARIO PARA APELACIONES/INQUIETUDES DEL PARTICIPANTE COMPLETE EL FORMULARIO Y ENVIELO POR FAX O POR CORREO 4305 University Avenue, Suite 200 San Diego, CA FAX (619) Si usted cree que este caso implica una emergencia, llame a Sharp Health Plan inmediatamente al (619) , o sin cargo al (800) Información Sobre el Participante Nombre (Apellido, Nombre, Inicial Intermedia) Número de Identificación del Participante Número de Teléfono (Día) Número de Teléfono (Tardes) Información Sobre el Paciente (Si el Paciente no es el Participante) Nombre (Apellido, Nombre, Inicial Intermedia) Número de Identificación del Participante Número de Teléfono (Día) Número de Teléfono (Tardes) Información Sobre el Médico (Si aplica) Nombre del Médico/Proveedor/Grupo Médico Número de Teléfono G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (Spanish).doc Page 1 of 2
5 Instrucciones: Describa brevemente los detalles específicos del problema e identifique cuándo ocurrieron los hechos. POR FAVOR, SEA ESPECIFICO. Díganos por favor cuál es el resultado que desea obtener y cómo piensa usted qué el Plan puede resolver su inquietud. Si usted tiene copias de documentos, cuentas, cheques u otra correspondencia relacionada con este problema que pueda ayudar en la solución del mismo, haga el favor de adjuntarla a este formulario. Si usted necesita más páginas para describir el problema, por favor anéxelas al formulario. Firma del Participante /Paciente Yo certifico que esta información es verdadera y correcta. Fecha El Departamento de Atención Administrada de la Salud de California está a cargo de regular los planes de servicios de atención de l a salud. Si tiene una queja contra su plan de salud, primero debe llamar por teléfono a su plan de salud al y emplear el proceso de presentación de quejas de su plan de salud antes de ponerse en contacto con el Departamento. La utilización de este procedimiento de presentación de quejas no prohíbe los derechos o remedios legales que usted pueda tener a su disposición. Si necesita ayuda con una queja que involucra una emergencia, una queja que su plan de salud no resolvió de manera satisfactoria o una queja que permaneció sin resolución durante más de 30 días, puede llamar al Departamento para que lo asistan. Es posible que también cumpla con los requisitos para una Revisión Médica Independiente (IMR, por su sigla en inglés). Si cumple con los re quisitos para una IMR, el proceso de la IMR brindará una revisión imparcial de las decisiones médicas tomadas por un plan de salud vinculadas a la necesidad médica de un servicio o tratamiento propuesto, de decisiones de cobertura de tratamientos de índole experimental o de investigación, y de las disputas de pago de servicios médicos de emergencia o de urgencia. El Departamento también tiene un número de teléfono sin cargo (1-888-HMO-2219) y una línea TDD ( ) para personas con dificultades del oído y del habla. El sitio de Internet del Departamento, presentación de quejas, solicitudes de IMR e instrucciones en línea., contiene formularios de G:\Common\CUSTOMER SERVICE\Reference\Appeal-Grievances\MEMBER GRIEVANCE FORM (Spanish).doc
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