Provider Resources

Member Grievance and Appeals Process

  • A complaint (or grievance) is when a member has a problem with SFHP or a provider, or with the health care or treatment from a provider.
  • An appeal is a request for review of services that has been denied, modified, or delayed by SFHP or one of its contracted Medical Groups.

Member Grievances
The SFHP Grievance process is designed to resolve member concerns in a manner that is accessible, timely and thorough. There is no time limit to file a grievance. A member or member representative can file a complaint with us at any time by phone, in writing, online, or in person. The grievance process is available across all lines of business. SFHP will provide a written resolution within thirty (30) calendar days for standard member grievances. A member or member representative can also request that a grievance be expedited if the member’s health is at immediate risk. A clinician will review the request and decide whether the grievance meets criteria for expedited processing. SFHP will provide a written resolution for Expedited Member Grievances within 72 hours from the time of receipt.

Member Appeals
A Member Appeal is a request for review of services that has been denied, modified, or delayed by SFHP or one of its contracted Medical Groups. If services have not been rendered, providers (with permission from the member) may file a Member Appeal within sixty (60) days of the Notice of Action letter for Medi-Cal members and 180 days from the Notice of Action letter for Healthy Workers HMO and Healthy Kids HMO. SFHP will provide a written resolution, called a Notice of Appeal Resolution, within thirty (30) days of receipt of the Member Appeal. Providers may also request that a Member Appeal be expedited if the member’s health is at immediate risk. SFHP will provide a written resolution for Expedited Member Appeals within 72 hours from the time of receipt.

If the member is a Medi-Cal member currently getting treatment for previously authorized services and wants to continue getting treatment, the provider must ask for an appeal within ten (10) days from the date the Notice of Action letter was postmarked or delivered, OR before the date the Notice of Action says that the previously authorized services will stop. The provider must say that the Medi-Cal member wants to keep getting treatment when the Member Appeal is filed.

After an authorization has been denied, the provider or member may submit a Member Appeal to SFHP by calling the SFHP Customer Service Department at 1(415) 547-7822, in writing by submitting the Grievance and Appeal Form via mail to SFHP Grievance Coordinator, P.O. Box 194247, San Francisco, CA 94119 or fax to 1(415) 547-7825, or electronically on SFHP.org using the Online Grievance Form. An SFHP clinician who is different form the SFHP clinician who issued the original denial will evaluate the Member Appeal.

SFHP only has one level of appeal for denied authorizations; denials that are upheld by SFHP cannot be appealed to SFHP again. Therefore, please gather all relevant documentation and clinical information that may affect the outcome of the dispute before submitting the appeal. Denials that are upheld may be appealed by applying for an Independent Medical Review (IMR) from the Department of Managed Health Care or, if the member is a Medi-Cal member, by requesting a State Fair Hearing from the Department of Social Services.  The Notice of Appeal Resolution will include information on how to request an IMR and/or State Fair Hearing.

SFHP processes all Member Appeals except Member Appeals regarding authorization decisions made by Kaiser Foundation Health Plan and Beacon Health Options. SFHP has delegated review of Member Appeals and Grievances to Kaiser Foundation Health Plan and Beacon Health Options only. Providers wishing to appeal authorization decisions made by Kaiser Foundation Health Plan or Beacon Health Options should submit such Member Appeals to Kaiser Foundation Health Plan or Beacon Health Options directly.

The links below contain information on our member grievance policy and multiple-language member grievance forms for your practices’ waiting rooms:

 

 

Member Grievance Form