Seaside Health Plan has a formal process for reviewing member grievances and appeals. This process provides a uniform and equitable treatment of your grievance/appeal and a prompt response. Seaside Health Plan shall ensure that all enrollees have access to and can fully participate in the grievance system by providing assistance for those with limited English proficiency or with visual or other communicative impairment. Such assistance shall include, but is not be limited to, translation of grievance procedures, forms and plan responses to grievances, as well as access to interpreters, telephone relay systems and other devices that aid disabled individuals to communicate.
A grievance is a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration, or appeal made by a member or the member’s representative. When the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance. Members have up to 180 calendar days from the date of an incident or dispute, or from the date the member receives a denial letter, to submit a grievance or appeal to Seaside Health Plan.
You may file a grievance in one of the following ways:
- Telephone - Call the Member Services phone number on your Seaside Health Plan ID card or 1 (844) 805-8700.
- Online - Submit your grievance online by logging into the member portal and filling out the GRIEVANCE FORM. Please attach any available documents.
- Mail - Download the Grievance Form here or on the member portal and mail the completed form with any attachments. Please, write neatly.
Seaside Health Plan, Attn: Member Grievance
17360 Brookhurst StreetFountain Valley, CA 92708
Information you provide us becomes part of the permanent grievance record. You will be sent an acknowledgement within 5 calendar days and a response within 30 calendar days of us receiving this form or your call.
The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-844-805-8700 (For TDD, call (855) 833-7747) and use your health plan's grievance process before contacting DMHC. 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 DMHC 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. DMHC 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. DMHC's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.