Appeals and Grievances

A grievance is an expression of dissatisfaction (other than an organization determination) with any aspect of the operations, activities, or behavior of a health plan, or its providers, regardless of whether remedial action is requested. Examples of grievances include:

• Problems getting an appointment, or having to wait a long time for an appointment
• Disrespectful or rude behavior by doctors, nurses, or other plan clinic or hospital

Members can file a complaint with their respective health plan by phone, mail, or through the health plan’s website. Health plans are required by law to have a grievance process in place to resolve enrollee complaints within 30 days. Search for Brown & Toland Physicians’ contracted health plans below to locate the appropriate health plan form to complete.

If the health plan denies the request for medical services or treatment, a complaint (grievance/appeal) may be filed with the respective health plan. You can request an Independent Medical Review (IMR) with the California Department of Managed Health Care (DMHC) if there is a disagreement the health plan’s decision, or it has been at least 30 days since the complaint has been filed with the health plan. The DMHC staff will determine whether the issue qualifies for an IMR.

Physician Dispute Resolution

If a physician wants to challenge, appeal, or request reconsideration of a claim or reimbursement, please see the bottom of webpage for Physician Disputes Resolution information within the provider portal.

Members and providers may request, free of charge, a copy of the actual benefit provision, guideline, protocol, policy or other similar criterion on which a determination is based, by calling the health plan directly or Brown & Toland Customer Service at 415-972-6002.

Health Plan forms for Members to Begin the Appeal or Grievance

Aetna

• Member Complaint and Appeal Form
• Request for an Appeal of Medicare Advantage Plan Authorization Denial
• Practitioner and Provider Compliant and Appeal Request
• Help filing a complaint, grievance or appeal

Anthem Blue Cross Blue Shield

• Member Grievance Form
• Provider Appeal Form
• Medicare: Complaints, Grievances and Appeals

Blue Shield

• Member Grievance Form
• Provider Dispute Resolution Request Form
• Cancellation of Health Coverage Grievance Form
• Notification of January 2021 Updates to the Blue Shield HMO IPA/Medical Group Procedures Manual

Cigna

• Request for Health Care Professional Payment Review
• Health Care Professional Application to Appeal a Claims Determination
• Provider Dispute Resolution Request
• Request for Provider Payment Review
• Healthcare Provider Billing Dispute Resolution Instructions and Form
• Healthcare Provider Retained Claims Instructions and Form
• California Customer Grievance Form PDF
• California Member Grievance Form Online

Health Net

• HMO Medicare Programs Request for Reconsideration (Appeal) Part C
• PPO Medicare Programs Request for Reconsideration (Appeal) Part C
• Amber HMO SNP Member Grievance/Complaint Form
• Health Net Appeals and Grievances electronic form

SCAN

• File a Grievance

San Francisco Health Plan

• Member Grievance Form
• Grievance Information

Sutter Health

• Member Grievance Form
• Continuity of Care Request Form
• Provider Dispute Form

United Health

• Member Grievance Form
• Claims Reconsideration Request Form

Contact Information for Brown and Toland Physicians’ Appeals and Grievances Department:

Email:  [email protected]
Telephone:  415-972-4586
Fax:  415-972-4149

Mail:
Brown & Toland Physicians
Attn: Appeals & Grievance Department
PO Box 72710
Oakland, CA 94612

Resources:

• Medicare Patient Rights and Protections
• Medicare Complaint Form
• DMHC Provider Complaints
• DMHC Patient Compliant form