If you are not happy with services received, or have questions about the service or care given to you, you have the choice to talk about it with your medical home doctor. Your medical home doctor may be able to help you or answer your questions.
At any time, you, your Member Representative, or anyone you ask to, can file a grievance (or complaint) with the HWLA Program. A Member Representative is a person or persons chosen by the member, through a written statement, to represent them in the State of California as a healthcare proxy, or a trustee named in a durable power of attorney, or a court appointed guardian. Also known as a Personal Representative(s), a Member Representative can be a spouse, relative, friend, advocate, doctor, practitioner, or someone designated as a representative by the member under Durable Power of Attorney, or as a legal/court-appointed guardian.
HWLA can’t take away your health care benefits or do anything to treat you differently from anyone else if you file a grievance or an appeal, or use any of your privacy rights in this handbook.
What Is A Grievance?
A grievance is a formal statement of dissatisfaction or complaint that is given to HWLA to be investigated and resolved.
- You have the right to file a grievance within 60 calendar days from the date that something happens which makes you unhappy with the service or care given to you by your medical home doctor, specialist, hospital, pharmacy and/or HWLA staff.
How To File A Grievance
You have many ways to file a grievance. You can do any of the following:
Fill out a grievance form at your medical home. Your medical home will have grievance forms available in its clinic. Staff at your medical home will help you fill out the form if you want them to.
Write, visit, fax or call the HWLA Grievance Coordinator.
Administrative Grievance Coordinator
1100 Corporate Center Drive, Suite 100
Monterey Park, CA 91754
The HWLA Program can help you over the phone or in person, to fill out the grievance form. Or we can send you a grievance form to fill out and send back to us.
You do not have to use the grievance form. You may state your grievance in a letter or other writing which is given to HWLA.
We will make interpreting services or language help available to you to help with the grievance process.
What Happens To Your Grievance?
We will look into your grievance. You may give us information or papers that will help us understand your position or that support it. You may speak for yourself during the grievance process or you may choose someone else to act for you, like a friend or family member. This person does not have to qualify as a Member Representative.
In most cases, you will receive a letter stating that HWLA received your grievance and is working on it. Then, within 60 calendar days of getting your grievance, HWLA will send you a letter explaining its decision. If your grievance is easy to resolve, we will state that we got your grievance and explain our decision in the same letter.
If you receive a Notice of Action letter and don’t agree with the decision, you have the right to appeal this decision.
What Is An Appeal?
An appeal is a written or oral request from a HWLA member for the review of an “action.” An action is when HWLA:
- Decides you do not qualify, or not longer qualify, for HWLA;
- Decides that you will not get a service or will get less than your doctor asked for;
- Decides that you will no longer get or will get less of a service that you were already getting;
- Does not provide services to you timely; or
- Does not process your appeal in a timely manner.
- A notice of action is a letter you get that says that an “action” has happened.
How To File An Appeal
An appeal of an action must be filed within 60 calendar days of the date of the Notice of Action letter that you receive.
You may file an appeal by filing out an appeal form. Your medical home should have copies of the appeal form for your use. You may also appeal by writing to HWLA Member Services. If you do not use the form, you should be sure to state the date of the Notice of Action, the type of action you are unhappy about and why you think that it is wrong.
You may also call Members Services and they will help you file the appeal, including helping you complete an appeal form. Member Services’ address and phone number are:
1100 Corporate Center Drive, Suite 100,
Monterey Park, CA 91754; 1-877-333-4952
If you need interpretation services, language or any other form of help in order to take part in the appeal process, we will provide them.
HWLA may take as long as 45 days to decide your appeal. If you believe that waiting this long could seriously put your life or health at risk, or put at serious risk your ability to get back the most function possible, you can ask for an “expedited appeal.” Expedited appeals are decided, and you will be told about the decision, within 3 business days of when we get the appeal request.
How To Keep Services Going While Your Appeal Is Going On
In some cases you may not agree with a HWLA decision to limit or end services you are already getting. It may be possible for you to have those services continue while your appeal is going on. To have treatment continued, the following four requirements must all be met:
- You ask for your appeal within 10 days of the date of the Notice of Action letter or by the effective date of the action, whichever is later;
- The services must have been ordered by a HWLA provider;
- The original period of approved services has not ended; and
- You must directly ask to keep the treatment going while the appeal is pending.
If HWLA is correct, and the appeal determines that the treatment should have been stopped or limited, you will have to pay for the services you received while the appeal was going on. If the appeal determines that you should have received the treatment, then you will not be expected to pay anything for the care.
Except as discussed above, an action is effective while the appeal process goes on; filing an appeal does not stop the action from taking place.