Members: Report a Problem
Report a Problem / File a Grievance
Solving Problems
San Francisco Health Plan wants you to have the best care and service possible. We want to hear from you when you are happy with your health care services, and to help you resolve any problems you may have.If there is a problem, try to talk about it when it first happens. Talking with your family’s PCP or other providers may be the best way to get the issue resolved quickly.
If the problem is not resolved, call our Customer Service Team at (800) 288-5555, Monday through Friday, 8:30 am to 5:30 pm. We will work with you to fix the problem. If we still cannot resolve the problem, you may file a formal complaint or “grievance.” which is any expression of dissatisfaction.
The Complaint/Grievance Process
If your complaint or problem is not resolved, it may be reviewed under our Grievance Process. Filing a complaint or grievance is your right, and we will not discriminate against you. You will not be disenrolled or lose eligibility for filing a complaint or a grievance.
You may file a grievance verbally or in writing. Grievance forms are available at each PCP’s office, from our Customer Service Team, and you may even download the form or file it electronically from this page (see below for more information). If you need help filling out the form, need translation services, or want a referral to community advocates, please contact our Customer Service Team.
If you are a San Francisco Health Plan member and would like more information about the grievance process, please refer to the Evidence of Coverage in your Member Handbook. If you need a copy of your Member Handbook, contact our Customer Service Team.
Medi-Cal Office of the Ombudsman
If you are a Medi-Cal member and are having trouble getting services or have other complaints, you also have the right to contact the Department of Health Care Service’s Office of the Ombudsman or the California Department of Social Services to request a State Hearing. A State Fair Hearing is an administrative procedure by which members with a grievance can present their cases directly to the State of California for resolution.
The Ombudsman Office can be reached toll-free at (888) 452-8609. The TDD number is
(800) 430-7077. Its office hours are Monday-Friday, 8:00am to 5:00pm, closed on State holidays.
Information regarding the State Fair Hearing process is available by calling
(800) 952-5253, (800) 430-7077 (TDD) or by writing:
California Department of Social Services, State Hearing Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA 94244-2430
Or Fax to:
State Hearings Division Fax Number: (916) 651-5210 or (916) 651-2789
When you write a letter to ask for a State Hearing, be sure to include your name, address, phone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name address and phone number to the form or letter. If you need a free interpreter, tell us what language you speak.
After you ask for a hearing, it could take up to 90 days for your case to be decided and an answer sent to you. If you believe waiting that long will seriously jeopardize your life or health or ability to attain, maintain or regain maximum function, ask your doctor or San Francisco Health Plan for a letter. The letter must explain how waiting for up to 90 days for your case to be decided will seriously jeopardize your life or health or ability to attain, maintain or regain maximum function. Then ask for an expedited hearing and provide the letter with your request for a hearing.
Important Message From the Department of Managed Health Care
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first use your health plan's grievance process before contacting the department. 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 the department 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.
The department also has a toll-free telephone number (888) 466-2219 and a TDD line at (877) 688-9891 for the hearing and speech impaired. The department's Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
There are SIX ways to file a grievance:
| 1 | Online by filling out this Grievance Form. |
| 2 | Call San Francisco Health Plan at (800) 288-5555, Monday through Friday, 8:30 am to 5:30 pm, and request a Grievance Form. |
| 3 | Visit the San Francisco Health Plan offices and file in person. For our address and a map please visit our Contact Us page, or call (800) 288-5555, Monday through Friday, 8:30 am to 5:30 pm. |
| 4 |
Write a letter describing the problem and mail it to San Francisco Health Plan. For an address please visit our Contact Us page, or call (800) 288-5555, Monday through Friday, 8:30 am to 5:30 pm. |
| 5 | Download and complete Grievance Form in your language:
Please visit our Contact Us page for mailing information |
| 6 | You may also file a grievance directly through your doctor's office. |
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