Member grievance and appeals process

Member rights

Anthem Blue Cross (Anthem) members have the right to seek resolution of issues through our grievance and appeal (G&A) process. The issues may involve dissatisfaction of concern about a contracted provider or access to services.

 

Independent medical review

After exhausting the Anthem grievance and appeal process, if a member is still dissatisfied with a decision, the member has the right to request an independent medical review (IMR) from the following entities:

• California Department of Managed Health Care:
  • Members may request an IMR if eligible for an expedited review or an urgent grievance or appeal.
• Anthem and all delegated entities must adhere to the decision and ensure authorization is issued within five working days of the IMR decision and that the member can readily access services. Anthem’s G&A team will communicate the decision to our delegated entities.

 

State fair hearing

Medi-Cal Managed Care (Medi-Cal) members may request a state fair hearing with the California Department of Social Services (CDSS) after exhausting the Anthem appeal processes or if Anthem fails to resolve an appeal request within the required time frames. The state fair hearing must be filed within 120 days from the date of the Notice of Appeal Resolution.

 

Once the CDSS receives the member’s request:

• The CDSS sends a notice of the hearing request to Anthem.
• Upon receipt of the request, all documents related to the request are forwarded to the CDSS.
• The CDSS notifies all parties of the date, time and place of the hearing. Representatives from our administrative, medical and legal departments may attend the hearing to present testimony and arguments. Our representatives may cross-examine the witnesses and offer rebutting evidence.
• An administrative law judge renders a decision in the hearing within 90 business days of the date the hearing request was made.
• If the judge overturns the Anthem position, Anthem and all delegated entities must adhere to the judge’s decision and ensure authorization is issued within 72 hours of the state fair hearing decision and that the member can readily access services. Anthem’s G&A team will communicate the decision to our delegated entities.

 

If you have any questions

You can call our Customer Care Center for Medi-Cal Managed Care outside L.A. County at 1-800-407-4627 or our Customer Care Center for Medi-Cal Managed Care inside L.A. County at 1-888-285-7801.