The Arta IPAs’ Customer Service Representatives are available to assist you if and when problems or concerns arise regarding your health care services. Please call 1-800-780-8879, Monday through Friday 8:00 AM to 4:30 PM, if you require assistance in filing an appeal or grievance.
If Arta Western Medical Group makes a decision not to authorize services that your doctor has requested, you will receive a copy of that decision in writing. The letter that is sent to you at your home will also contain the following information, which directs you on how to request an appeal.
If you do not agree with a denial decision, you may:
1) File a grievance with your health plan within ninety days from the date of a denial decision (please call CalOptima at 1-888-587- 8088 to request a grievance form), or
2) Ask for a state hearing within ninety days from the date of a denial decision.
You can file a grievance with your health plan and ask for a state hearing at the same time.
You will not have to pay for either of these.
Grievances
You may ask for a grievance no later than ninety days from the date of a denial decision by calling CalOptima at 1-888-587-8088 or TTY/TDD at 1-714-246-8496, Monday through Friday from 8:00 am to 5:30 pm; or by faxing a letter to CalOptima at 1-714-246-8562, or by sending a letter to CalOptima at 1120 West La Veta Avenue, Orange, CA 92868, Attn: Grievance and Appeals Resolution Services. You may submit written comments, documents, or other information that you feel is relevant to your grievance or appeal. You can also name a relative, friend, advocate, doctor, lawyer or someone else to act for you. Your grievance or appeal will be decided by a physician who was not involved in making any other decision in your case. Your doctor will also be advised of your grievance or appeal. CalOptima will review its decision based on your grievance or appeal and you will get an answer within thirty days. If you think that waiting thirty days will harm your health, be sure to say why when you ask for your grievance or appeal. Then you may be able to get an answer within three calendar days.
State Hearings
You may ask for a state hearing in writing. Fill out the enclosed form or send a letter to:
California Department of Social Services
State Hearing Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430
Alternatively, you may call 1-800-952-5253 to ask for a state hearing. This number can be very busy so you may get a message to call back later. If you have trouble hearing or speaking, you can call TDD 1-800-952-8349. If you want a state hearing, you must ask for it within ninety days from the date of a denial decision, UNLESS you and your doctor want to keep the treatment going that this Notice of Action is stopping or reducing. Then, you must ask for a state hearing within ten days from the date a denial decision was made. Please state that you want to keep getting your treatment during the hearing process.
If you use the enclosed form or 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 ninety days for your case to be decided and an answer sent to you. If you believe waiting that long will seriously jeopardize your life, your health, or your ability to attain, maintain or regain maximum function, ask your doctor or CalOptima for a letter. The letter must explain how waiting for up to ninety days for your case to be decided will seriously jeopardize your life, your health, or your ability to attain, maintain or regain maximum function. Then ask for an expedited hearing and provide the letter with your request for hearing.
Legal Help
You may speak for yourself at the state hearing or have someone else speak for you, including a relative, friend or attorney. You must obtain the services of this other person yourself. You may be able to get free legal help. Call the Orange County Health Consumer Action Center at 1-800-834-5001 or the Legal Aid Society of Orange County at 1-800-834-5001 to request help.
Other Information
CalOptima wants to try to help you with your problem, so we hope you will call us first.
Form to File a State Hearing
You can ask for a state hearing by calling 1-800-952-5253.
TDD users, call 1-800-952-8349.
Or you can fill out this form and fax it to State Hearing Support at 1-916-229-4110.
Or you can mail this page to: California Department of Social Services
State Hearing Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430
For CalOptima Healthy Families program members:
For free help filling out this form, call the legal help phone number listed in the "Legal
Help" section above.
I do not agree with the decision about my health care. Here's why:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(If you need more space, use another piece of paper. Make a copy for your records.)
Check these boxes only if they apply to you:
(1) I want the person named below to represent me. She/he can see my
medical records that relate to this hearing, come to the hearing, and
speak for me.
Name: __________________________
Address: ________________________ Phone Number: _____________________
________________________
(2) I need a free interpreter. My language or dialect is:
_________________________________
(3) I also want to file a grievance against the health plan. I understand the
State will send my health plan a copy of this form.
(4) My situation is urgent. I need a quick decision and cannot wait 90 days
because: (Explain what may happen without a quick decision. As discussed
in the "Your Rights" information notice, you will also need a letter from
your doctor or health plan if you want an expedited hearing).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
(5) Please continue the service my Plan has stopped until my hearing.
My Name: ________________________ My Social Security Number: ___________
Address: _________________________
_________________________ Phone Number: _____________________
My signature: _______________________________ Today's Date: ____________
(After you complete this form, make a copy for your records.)
If Arta Western Medical Group makes a decision not to authorize services your doctor has requested, you will receive a copy of that decision in writing. The letter that is sent to you at your home will also contain the following information, which directs you on how to request an appeal.
How to Dispute This Determination
If you believe that the denial determination is not correct, you have the right to appeal the decision by filing a grievance with CalOptima. You submit your grievance within 180 days from the date of the denial decision. You or someone you designate (your authorized representative) may submit your grievance verbally or in writing. You may call CalOptaim to learn how to name your authorized representative.
There are two types of grievances: standard and expedited.
Standard Grievance Process
A standard grievance will be resolved within 30 days. CalOptima will notify you in writing of the decision within 30 calendar days of receiving your grievance.
Expedited/72 hour Grievance Process
CalOptima makes every effort to resolve your grievance as quickly as possible. In some cases, you have the right to an expedited grievance when a delay in the decision-making process might pose an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb, major bodily function, or if the normal timeframe for the decision-making process would be detrimental to your life, your health, or could jeopardize your ability to regain maximum function. If you request an expedited grievance, CalOptima will evaluate your grievance and health condition to determine if your grievance qualifies as expedited. If so, your grievance will be resolved within 72 hours. If not, your grievance will be resolved within the standard 30 days.
Submitting Your Grievance
Please submit a copy of your denial notice and a brief explanation of your situation, or other relevant information to CalOptima. CalOptima will document and process your standard or expedited grievance and provide you with written notification of the decision. You may write, call or fax your grievance to CalOptima.
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 CalOptima and use CalOptima’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 (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing- and speech-impaired. The department’s website: http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
The link to Arta Western Medical Group’s contracted Medi-Cal and Healthy Families Orange County program administrator, CalOPTIMA, is listed below:
http://www.caloptima.org