Report a Problem or File a Grievance

 

Solving Problems

San Francisco Health Plan wants you to have the best care and service possible. We want to hear from you when you are happy with your health care services, and if you need assistance, we want to help you resolve any problems you may have.

If there is a problem, try to address it when you first notice it. Talking with your family’s PCP or other providers may be the best way to get the issue resolved quickly.

If the problem is not resolved, call our Customer Service Team at 1(800) 288-5555, Monday – Friday, 8:30am to 5:30pm. We will work with you to fix the problem. If we cannot resolve the problem, you may file a formal complaint or “grievance,” which is any expression of dissatisfaction.

The Complaint/Grievance Process

If your complaint or problem is not resolved, it may be reviewed under our grievance process.  Filing a complaint or grievance is your right, and we will not discriminate against you. You will not be dis-enrolled or lose eligibility for filing a complaint or a grievance.

You may file a grievance verbally or in writing. Grievance forms from our customer service department are available at each PCP’s office, and you may even download the form or file electronically from this page (see below for more information). If you need help filling out the form, if you need translation services, or if you want a referral to community advocates, please contact Customer Service.

If you are a San Francisco Health Plan member and would like more information about the grievance process, please refer to the Evidence of Coverage in your Member Handbook.  If you need a copy of your Member Handbook, contact our Customer Service.

Medi-Cal Office of the Ombudsman

If you are a Medi-Cal member and are having trouble getting services or if you have other complaints, you also have the right to contact the Department of Health Care Service’s Office of the Ombudsman or the California Department of Social Services to request a State Hearing. This Fair Hearing is an administrative procedure in which members with a grievance can present their cases directly to the State of California for resolution.

The Ombudsman’s Office can be reached toll-free at 1(888) 452-8609. The TDD/TTY number is
1(800) 952-8349. Office hours are Monday – Friday, 8:00am to 5:00pm, closed on State holidays.

Information regarding the State Fair Hearing process is available by calling
1(800) 952-5253
, 1(800) 952-8349 (TDD/TTY) or by writing:

California Department of Social Services, State Hearing Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA 94244-2430

Or fax to:
State Hearings Division Fax Number: 1(916) 651-5210 or 1(916) 651-2789

When you write a letter to ask for a State Hearing, be sure to include your name, address, phone number, Social Security number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and phone number to the form or letter. If you need a free interpreter, tell us what language you speak.

After you ask for a hearing, it could take up to 90 days for your case to be decided and an answer sent to you. If you believe waiting that long will seriously jeopardize your life or health or ability to attain, maintain or regain maximum function, ask your doctor or San Francisco Health Plan for a letter. The letter must explain how waiting for up to 90 days for your case to be decided will seriously jeopardize your life or health or ability to attain, maintain or regain maximum function. Then ask for an expedited hearing and provide the letter with your request for a hearing.

Important Message from the Department of Managed Health Care

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 use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not preclude 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, 1(888) 466-2219, and a TDD/TTY line at 1(877) 688-9891 for the hearing and speech impaired. The department’s Internet website www.hmohelp.ca.gov has complaint forms, IMR application forms, and instructions online.


There are SIX ways to file a grievance:

      1. Online by filling out this Grievance Form.
      2. Call San Francisco Health Plan at 1(800) 288-5555, Monday – Friday, 8:30am – 5:30pm, and request a Grievance Form.
      3. You may also file a grievance in person. Our Service Center address is 7 Spring Street, San Francisco, CA 94104. Office Hours are Monday through Wednesday and Friday 8:30am to 5:00pm; Thursday 8:30am to 4:00pm. Call 1(415) 777-9992 to schedule an appointment.
      4. Write a letter describing the problem and mail it to San Francisco Health Plan. For an address please visit our Contact Us page, or call 1(800) 288-5555, Monday – Friday, 8:30am – 5:30pm.
      5. Download and complete a Grievance Form in your language:

        Please visit our Contact Us page for mailing information.

      6. You may also file a grievance directly through your doctor’s office.

For grievances related to services provided by Beacon Health Strategies, you may also file a grievance directly with Beacon by contacting 1(855) 371-8117.