How to File a Grievance
Seaside Health Plan may not be your Primary Health Plan to file an online grievance. Your Primary Health Plan has a formal process for reviewing member grievances and appeals. This process provides a uniform and equitable treatment of your grievance and appeal and a prompt response.
Please review your Member ID Card to determine your Primary Health Plan and where to file an online grievance. Please click the appropriate link below to be directed to your Primary Health Plan’s online grievance website.
Seaside Health Plan helps ensure your grievance is given the attention you deserve even when we are not your Primary Health Plan by forwarding all grievances and appeals to your Primary Health Plan within 24 hours of receipt.
When Seaside receives a request from your Primary Health Plan, Seaside forwards the request for information to your doctor or other provider within 1 business day. Seaside monitors to ensure we receive the response within 7 calendar days. Then forwards information we received to the Primary Health Plan within 24 hours of receipt.
Your Primary Health Plan is responsible for the correspondence, resolution and forwarding your case to Independent Medical Review if needed.
Further Appeal Rights
If you are dissatisfied with your Primary Health Plan’s answer, you may be able to pursue one or more of the following appeal processes, depending on your situation and the appeal information contained in your Primary Health Plan’s Evidence of Coverage. If you need assistance please contact Member Services at the number on the back of your Primary Health Plan’s member ID card.
File a complaint with the Department of Managed Health Care (DMHC) provided that your health coverage is governed by them. Click on the following link to be directed to the DMHC web site http://www.dmhc.ca.gov/.
If your health coverage is not governed by the DMHC, it may be governed by the Department of Insurance. Please contact your Primary Health Plan’s Member Services if you are not sure which entity governs your health coverage. Your Primary Health Plan’s Member Services number is on the back of your Primary Health Plan’s member ID card.
- Request Independent Medical Review. Independent Medical Review is available for decisions to deny payment on the basis that the services are not medically necessary or that they are considered investigational or experimental. If your grievance involves a denial of health care service, information on the Independent Medical Review process will be provided in the letters sent to you by your Primary Health Plan.
- Have your case reviewed in an administrative hearing if you are a Medicare beneficiary or a MediCal member. Those rights are identified in your Primary Health Plan’s Evidence of Coverage.
- Seek legal remedies in a court of law.