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Appeals and Grievances

We at Physicians Medical Group work very hard to keep your health care experience problem free, but we acknowledge that disputes may arise.

Each of our Health Plans respects your right to Appeal any denied claim or service. You also have a right to file a Grievance (complaint) for denied, delayed or modified covered services or if you are dissatisfied with your quality of care, access, or any other quality issues. Physicians Medical Group works closely with each of the Health Plans in resolving these Appeals and Grievances.

If you are receiving a bill from a Provider of Service for anything other than your specified copayments and deductibles, but have not received a denial letter, call Member Services at (408) 937-3642 for assistance. Almost always, if you are receiving a bill, it is because the Provider has not submitted the claim to the appropriate payer.

Appeals and Grievances must be made directly to your Health Plan by completing and forwarding a Member Grievance Form.

If you have received a letter of denial from Physicians Medical Group or your Health Plan for payment of a claim or authorization of services you may file an Appeal. The Health Plan will request documentation from Physicians Medical Group and your Physician, review the decision, and issue a determination.

If the appeal is in regard to authorization for care that is immediately vital to your health, you may file an Expedited Appeal.

If you wish to make a formal complaint regarding the quality of care or service you have received, you may file a Grievance. The Health Plan will initiate a case review, request a response and any related medical records from Physicians Medical Group and your Physician, and issue a formal determination to you.

Your Member Materials from your Health Plan or your Health Plan’s website will give you specific instructions for filing an Appeal or Grievance, or you can call the Customer Service phone number printed on your card. Be sure to tell the representative that you would like to file an Appeal or Grievance.

When you receive your Health Plan’s determination, if you are still unhappy, you may submit your dispute to the California Department of Managed Health Care, which oversees all HMO care in California . Your determination letter from the Health Plan will have this contact information, or you may call DMHC at 1-888-HMO-2219.

If you are uncertain about filing an Appeal or Grievance, call our Member Service Department for assistance at (408) 937-3642.