CALIFORNIA - Pacificare Health Systems

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Section 9 – Organization Determination,
Appeals and Grievance Procedures
General complaints about increases in
member liability or benefit design
Involuntary Disenrollment situations (see
Section 8)
If you disagree with PacifiCare’s decision
to extend the time frame on a standard or
expedited request
If you disagree with PacifiCare’s decision
to extend the time frame on a standard or
expedited Appeal
If you disagree with PacifiCare’s
decision to process your Organization
Determination request for service under
the standard fourteen (14) day time frame
rather than expedited seventy-two (72)hour
time frame
If you disagree with PacifiCare’s decision
to process your reconsideration (Appeal)
request under the standard thirty (30)day
time frame rather than the expedited
seventy-two (72)-hour time frame
To use the formal Grievance procedure,
submit your Grievance in writing to PacifiCare
Appeals and Grievances Unit.
However, complaints about a decision
regarding payment or provision of Covered
Services that you believe are covered by
Medicare and should be arranged or paid for
by PacifiCare must be appealed through the
Secure Horizons Medicare Advantage Plan
Medicare Appeals procedure (see above).
Complaints That Do Not Relate to
Quality of Medical Care Issues
PacifiCare reviews complaints that do not
relate to quality of medical care issues in
consultation with appropriate PacifiCare
departments. PacifiCare will write you to
acknowledge your complaint and let you
know how PacifiCare has addressed your
concern within thirty (30) days of receiving
your written Grievance. If you request an
expedited grievance related to PacifiCare’s
decision to invoke an extension on your
request for an organization determination
or reconsideration, or PacifiCare’s decision
to process your expedited request as a
standard request, PacifiCare will acknowledge
your grievance within twenty-four (24)
hours of receipt and notify you in writing
of PacifiCare’s conclusion within three (3)
calendar days. In some instances, PacifiCare
will need additional time to address your
concern. If additional time is needed,
PacifiCare will keep you informed regarding
the status of your Grievance. We must notify
you of our decision about your grievance as
quickly as your case requires based on your
health status, but no later than 30 calendar
days after receiving your complaint. We may
extend the time frame by up to 14 calendar
days if you request the extension, or if we
justify a need for additional information and
the delay is in your best interest.
Complaints Involving Quality of Medical
Care Issues
All complaints that involve quality of medical
care issues are referred to PacifiCare’s Health
Services Department for review. Complaints
that affect a Member’s immediate condition
will receive immediate review. PacifiCare
will investigate the complaint, consulting
with your Contracting Medical Group and
appropriate PacifiCare departments, and
reviewing medical records as necessary.
You may need to sign an authorization to
release your medical records. PacifiCare will
confirm receipt of your complaint within
thirty (30) days of receiving your complaint,
whenever possible. The results of the Quality
Management review are confidential. We
must notify you of our decision about your
grievance as quickly as your case requires
based on your health status, but no later
than 30 calendar days after receiving your
complaint. We may extend the time frame
by up to 14 calendar days if you request
the extension, or if we justify a need for
additional information and the delay is in
your best interest.
QIO Quality of Care Complaint Process
If you are concerned about the quality of
care you have received, you may also file a
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B