A grievance is a formal complaint you make when you are not happy with health care you received. This could mean services from your doctor, a specialist, clinic staff, a lab, a pharmacy, or SFHP.
The grievance can be made by you, or someone you have chosen to speak for you.
SFHP can help you with problems you may have with SFHP staff or your provider. It can also be about health care services you have gotten or want to receive.
Filing a grievance helps SFHP learn about your healthcare experience. Sometimes a grievance is the only way SFHP finds out that there is a problem. Grievances help SFHP change parts of the health system that cause problems for our members.
Sometimes members file grievances because they can’t get the health services they need or want. If you have had a bad experience because you weren’t able to get needed care, SFHP can help you understand the health system and what is available to you.
- Waiting too long for an appointment, or in the provider’s office.
- Not having an interpreter when you need one.
- Not agreeing with your provider(s) about your treatment, even after talking to them about your concerns.
- Feeling that your provider treats you with a bad attitude.
- Feeling that you are being discriminated against based on things about you. This may include your race/ethnicity, gender identity or expression, sexual orientation, disability status, and financial or housing situation.
- Poor customer service from clinic staff.
- Feeling that your health information is not being protected.
- If you are unhappy about any part of your care.
For Medi-Cal, SFHP sends grievance letters in Chinese, Spanish and Vietnamese.
For Healthy Workers HMO, SFHP sends grievance letters in Chinese, Spanish, Vietnamese, Russian and Tagalog.
You can get free interpreter services for any language by calling SFHP Customer Service at 1(415) 547-7800 or toll-free at 1(800) 288-5555.
Call SFHP’s Customer Service Department at 1(415) 547-7800
In person, at SFHP’s Service Center: 7 Spring Street, San Francisco CA 94104
Mail: P.O. Box 194247, San Francisco CA 94119
Online by filling out this Grievance Form
Directly through your provider’s office
SFHP and your provider should not treat you any differently because you filed a grievance. This means that SFHP, your provider, or clinic should not retaliate or discriminate against you in any way. If you feel you have been treated poorly because you filed a grievance, it is important to tell SFHP and file another grievance.
Filing a grievance has no effect on your Medi-Cal or Healthy Workers HMO coverage or benefits.
Some actions you take during the grievance process may affect parts of your care. For example, changing your provider or medical group may cause a delay in getting a refill. It could also take longer for you to see a specialist. SFHP’s staff can answer any questions you have about how these changes may impact you.
First, a doctor or nurse from SFHP reviews your grievance. They will check to see if your life or health is in immediate danger.
Next, SFHP talks to the health care providers involved in the grievance. SFHP shares with them what you said about your experience. SFHP also asks the provider for information and their perspective about the grievance.
SFHP reviews all the information it gets from the provider and member. Lastly, SFHP’s Grievance Review Committee decides on the response to the grievance. This includes the Chief Medical Officer and staff from the Compliance, Provider Network, Health Services, and Customer Service teams.
If your grievance is not urgent, SFHP will send you a letter within 5 calendar days. This letter will let you know that we received your grievance. SFHP will mail you another letter within 30 calendar days of when you filed your grievance. This letter will have SFHP’s response to your grievance.
A grievance is urgent when your life or health is in immediate danger. For urgent grievances, SFHP will call you to let you know that we received your grievance. You can also call the Department of Managed Health Care about your grievance at 1(888) 466-8819. SFHP will send you a written response within 3 calendar days after we get your urgent grievance.
Some types of medicine, tests, and treatments require that your provider submit a request to SFHP. This is called a prior authorization. Your provider will need to provide proof that the service is necessary for your care.
To find out if the service was approved, you can call SFHP Customer Service or ask your provider. You and your provider will receive a Notice of Action letter to let you know if the request has been denied. If it is denied, you can ask that the request be reviewed again by a different SFHP doctor. This is called an appeal. You will get another Notice of Action letter letting you know the decision of the appeal.
Usually it is your provider who would appeal if the service is not approved. Members can also file an appeal directly with SFHP by calling Customer Service.
Grievances and appeals received related to pharmacy services or prescription benefit starting January 1, 2022 for Medi-Cal members will be handled through Medi-Cal Rx’s Customer Service Center for triaging, research, and a ruling. You can call Medi-Cal Rx toll-free at 1(800) 977-2273.
If you have Medi-Cal, you have 60 days to appeal a denial of an authorization or payment for health care. When SFHP denies an authorization or payment, you will receive a letter explaining the denial, known as a Notice of Action (NOA) letter. The date listed on the NOA is the first day of the 60 days. When you appeal a decision about a payment or denial, a different SFHP doctor will review your case. If you are dissatisfied with something not involving a NOA, you can file a grievance at any time with SFHP.
If you have Healthy Workers HMO, you have 180 days to appeal a denial of an authorization or payment for health care. When SFHP denies an authorization r payment, you will receive a letter explaining the denial, known as a Notice of Action (NOA) letter. The date listed on the NOA is the first day of the 180 days. When you appeal a payment or a denial, a different SFHP doctor will review your case. If you are dissatisfied with something not involving a NOA, you can file a grievance within 180 days of the incident that caused your dissatisfaction.
If the experience or decision happened while you were a SFHP member, please file the grievance with SFHP.
If you were not an SFHP member when it happened, please file the grievance with your current health plan. You can also file the grievance with the Department of Managed Health Care at 1(888) 466-2219.
SFHP cannot prescribe medication. It also cannot force providers to prescribe medication or change your prescription. The provider who is treating you must decide what medicines are safe and will work best for you.
It is your right to have a second opinion from another provider if you do not agree with your doctor’s decision about your treatment or medication. You can tell your clinic that you want to be evaluated by another provider.
When deciding whether to pay for or authorize a treatment, SFHP may review whether it is needed for you. SFHP uses the information about your care that your doctor provides to make the decision. It also uses and nationally-recognized standards
Beginning on January 1, 2022, if you are an SFHP Medi-Cal member, Medi-Cal Rx decides whether to pay for or authorize your medication treatments.
The clinic’s role is to provide direct health care, triage your health concerns over the phone, schedule appointments, send referrals, and prior authorization requests.
SFHP reviews prior authorization requests and will approve or deny them based on medical need.
You can file a grievance directly with your clinic, or with SFHP. Your clinic may decide not to share the grievance you file with SFHP. The clinic may also follow a different process for handling grievances than SFHP.
You may file another grievance.
You can ask for an Independent Medical Review (IMR) of Consumer Complaint with the Department of Managed Health Care at 1(888) 466-2219, TDD 1(877) 688-9891. This option is available to Medi-Cal and Healthy Workers HMO members.
If you are a Medi-Cal member, you can ask the Department of Social Services for a State Fair Hearing at 1(800) 952-5253, TDD 1(800) 952-8349. This option is not available to Healthy Workers HMO members.
If you are a Medi-Cal member, you can file a complaint with the Medi-Cal Ombudsman office at 1(888) 452-8609. This option is not available to Healthy Workers HMO members.
If you do not want to file your grievance with SFHP, you can file your grievance directly with the Department of Managed Health Care at 1(888) 466-2219.
Yes, you can decide to not file a grievance. You can do this even after you have shared your experience with SFHP.
You can withdraw your grievance at any time.