Member Appeal
A Member Appeal is a request for review of services that has been denied, modified, or delayed by SFHP or one of its contracted Medical Groups. If services have not been rendered, providers (with permission from the member) may file a Member Appeal within sixty (60) days of the Notice of Action letter for Medi-Cal members and 180 days from the Notice of Action letter for Healthy Workers HMO. SFHP will provide a written resolution, called a Notice of Appeal Resolution, within thirty (30) days of receipt of the Member Appeal. Providers may also request that a Member Appeal be expedited if the member’s health is at immediate risk. SFHP will provide a written resolution for Expedited Member Appeals within 72 hours from the time of receipt.
If the member is a Medi-Cal member currently getting treatment for previously authorized services and wants to continue getting treatment, the provider must ask for an appeal within ten (10) days from the date the Notice of Action letter was postmarked or delivered, OR before the date the Notice of Action says that the previously authorized services will stop. The provider must say that the Medi-Cal member wants to keep getting treatment when the Member Appeal is filed.
After an authorization has been denied, the provider or member may submit a Member Appeal to SFHP by calling the SFHP Customer Service Department at 1(415) 547-7822, in writing by submitting the Grievance and Appeal Form via mail to SFHP Grievance Coordinator, P.O. Box 194247, San Francisco, CA 94119 or fax to 1(415) 547-7825, or electronically on SFHP.org using the Online Grievance Form. A SFHP clinician who is different form the SFHP clinician who issued the original denial will evaluate the Member Appeal.
SFHP only has one level of appeal for denied authorizations; denials that are upheld by SFHP cannot be appealed to SFHP again. Therefore, please gather all relevant documentation and clinical information that may affect the outcome of the dispute before submitting the appeal. Denials that are upheld may be appealed by applying for an Independent Medical Review (IMR) from the Department of Managed Health Care or, if the member is a Medi-Cal member, by requesting a State Fair Hearing from the Department of Social Services. The Notice of Appeal Resolution will include information on how to request an IMR and/or State Fair Hearing.
SFHP processes all Member Appeals except Member Appeals regarding authorization decisions made by Carelon Behavioral Health. SFHP has delegated review of Member Appeals and Grievances to Carelon Behavioral Health only. Providers wishing to appeal authorization decisions made by Carelon Behavioral Health should submit such Member Appeals to Carelon Behavioral Health directly.
Provider Disputes
SFHP offers a fair and cost-effective dispute resolution mechanism to providers who are dissatisfied with a claim, billing or contract determination. A Provider Dispute Resolution Request may be submitted in writing using the Provider Dispute Resolution Request Form. Dispute requests must be submitted within 365 days of SFHP’s most recent action on the disputed claim.
If SFHP never received a prior authorization request for services that have now been rendered, please submit a retrospective authorization request to SFHP’s Utilization Management Department.
Denied Authorizations
SFHP allows providers to appeal decisions that resulted in the denial of authorization for clinical services. A provider can file a Provider Dispute Resolution (PDR) to request reconsideration of a UM denial for clinical services that have already been rendered. Please follow instructions on the form when submitting a PDR.
To help ensure the expeditious resolution of the dispute, please include the following:
- A complete, signed Provider Dispute Resolution Request Form, including SFHP’s original claim number and a clear description of the dispute and the expected outcome
- Any relevant, additional documentation that may affect the outcome of the dispute
For further instructions on how to submit a Provider Dispute Resolution Request, please contact SFHP’s Claim Department at 1(415) 547-7818 ext 7115, Monday-Friday, 8:30am – 5:30pm, or email claimsinfo@sfhp.org.