Appeals and grievance process
How to file a grievance or request an appeal
We hope you will always be satisfied with your experience as a member of Scripps Health Plan, but we also understand this may not always be the case. If you are dissatisfied with the care or treatment you have received, if you were denied a service or benefit, or if you have any other concerns, you have the right to file an appeal or grievance with the health plan.
An appeal or grievance is a term used when an HMO member notifies their health plan that they are dissatisfied with the plan, a plan provider or a decision made by the plan. Contacting the health plan regarding the concern is called “filing an appeal or grievance."
An appeal or grievance may be filed for a variety of issues including:
- Timely access to care and availability of providers
- The health plan’s decision to deny, modify or delay a requested service
- Quality of care concerns
- Quality and cleanliness of provider offices
- Timeliness of services
- Benefit coverage, billing or financial concerns
- The health plan’s decision to cancel, rescind or not renew coverage
At Scripps Health Plan, it is our priority to provide superb health care and customer service. We encourage you to notify us if you are unhappy with any aspect of your care. If your concerns are related to a provider within our provider network, we suggest that you first discuss those concerns with the staff at the point of care. If you are not satisfied with the resolution provided, we welcome you to contact Scripps Health Plan customer service.
If you want to file an appeal or grievance, you may do so verbally, via facsimile, electronically or in writing:
- File a verbal appeal or grievance by calling 844-337-3700 or TTY/TDD 888-515-4065 (for the hearing and speech impaired).
- To file an appeal or grievance electronically, fill out the online GRIEVANCE FORM below
- To file an appeal or grievance via facsimile or in writing, print and fill out a GRIEVANCE FORM (PDF, 260 KB) and mail or fax it to:
Scripps Health Plan
Attention: Appeals & Grievances
Mail Drop: 4S-300
10790 Rancho Bernardo Road
San Diego, CA 92127
You will receive a written acknowledgement letter within five (5) days, notifying you that we have received your appeal or grievance. After conducting an investigation into your concerns, you will receive a final decision letter within thirty (30) days. You have the right to submit an expedited appeal or grievance if you feel that waiting thirty (30) days could seriously threaten your health or normal ability to function (including severe pain), or if you believe your enrollment has been or will be improperly canceled, rescinded or not renewed. An expedited request may be initiated by you or by your physician and you will be contacted immediately, acknowledging receipt of your expedited request. You will receive a written decision from us within three (3) calendar days. If we determine the request does not warrant expedited review, you will be contacted regarding our decision to convert your request to standard, and your appeal or grievance will be resolved within thirty (30) days.
If your prior authorization request for an outpatient drug has been denied as not being on the formulary, you, your designee or your provider may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization (IRO). You will be notified of the IRO’s decision within 72 hours for standard requests or 24 hours for expedited requests.
Department of Managed Health Care complaint process
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 844-337-3700 or TTY/TDD at 888-515-4065 (for the hearing and speech impaired) 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 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 (888-466-2219) and a TDD line (877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.