Reporting and Solving Problems

All of us at CalOptima Health PACE share responsibility for your care and your satisfaction with the services you receive. Our grievance procedures are designed to enable you and/or your representative to express any concerns or dissatisfaction you have so that we can address them in a timely and efficient manner. You also have the right to appeal any decision about our failure to approve, furnish, arrange for or continue what you believe are covered services, or to pay for services that you believe we are required to pay.

This page describes our grievance and appeals processes. You will receive written information about the grievance and appeals processes when you enroll and annually after that. At any time, should you wish to file a grievance, we are available to assist you. If you do not speak English, a bilingual staff member or translation services will be available to assist you with the process.

You will not be discriminated against because a grievance or appeal has been filed. CalOptima Health PACE will continue to provide you with all the required services during the grievance or appeals process. We will maintain the confidentiality of your grievance or appeal throughout the process, and information pertaining to your grievance or appeal will only be released to authorized individuals.

Definition: A grievance is a complaint, either written or oral, expressing dissatisfaction with the services provided or the quality of care. A grievance may include, but is not limited to:

The information below describes the grievance process for you or your representative to follow should you or your representative wish to file a grievance.

1. You can verbally discuss your grievance either in person or by telephone with PACE program staff of the center you attend. The staff person will make sure that you are provided with written information on the grievance process and that your grievance is documented on the Grievance Report form. You will need to provide complete information about your grievance so the appropriate staff person can help to resolve your grievance in a timely and efficient manner. If you wish to submit your grievance in writing, please send your written grievance to:

CalOptima Health PACE Quality Assurance Coordinator
13300 Garden Grove Blvd.
Garden Grove, CA 92843
Telephone: 1-714-468-1100
Fax: 1-714-468-1065
TTY: 1-714-468-1063

You may also contact our Quality Assurance department at 1-714-468-1100 to request a Grievance Report form and receive assistance in filing a grievance. TDD/TYY users can call 1-714-468-1063. Our Quality Assurance department will provide you written information on the grievance process. You may also access our website at www.caloptima.org to find information about the grievance process.

2. The staff member who receives your grievance will help you document your grievance (if your grievance is not already documented) and coordinate investigation and action. All information related to your grievance will be held in strict confidence.

3. You will be sent a written acknowledgement of receipt of your grievance within five (5) calendar days. Investigation of your grievance will begin immediately to find solutions and take appropriate action.

4. The CalOptima Health PACE staff will make every attempt to resolve your grievance within thirty (30) calendar days of receipt of your grievance , and you will receive a written letter with the resolution. If you are not satisfied with that resolution, you and/or your representative have the right to pursue further action.

5. In the event resolution is not reached within thirty (30) calendar days, you or your representative will be notified in writing of the status and estimated completion date of the grievance solution.

If you feel your grievance involves a serious or imminent threat to your health, including, but not limited to, potential loss of life, limb or major bodily function, severe pain, or violation of your participant rights, we will expedite the review process to a decision within 72 hours of receiving your written grievance and request for expedition. In this case, you will be immediately informed by telephone of:

Upon CalOptima Health PACE completion of the investigation and reaching a final resolution of your grievance, you will receive written notification that will provide you with a report describing the reason for your grievance, a summary of actions taken to resolve your grievance, and options to pursue if you are not satisfied with the resolution of your grievance.

If, after completing the grievance process, or participating in the process for at least thirty (30) calendar days, you or your representative are still dissatisfied, you or your representative may pursue the options described below. Note: If you feel that waiting thirty (30) calendar days represents a serious health threat, you and/or your representative need not complete the entire grievance process nor wait thirty (30) calendar days to pursue the options described below.

If you are covered by Medi-Cal only or by Medi-Cal and Medicare, you are entitled to pursue your grievance with the Department of Health Care Services, by contacting or writing to:

Ombudsman Unit
Medi-Cal Managed Care Division
Department of Health Care Services
P.O. Box 997413, Mail Station 4412
Sacramento, CA 95899-7413
Telephone:1-888-452-8609
TDD/TTY: 1-800-735-2922

State Hearing Process:

At any time during the grievance process, per California State law, you may also request a State hearing from the California Department of Social Services by contacting or writing to:

California Department of Social Services
State Hearing Division
P.O. Box 944243, Mail Station 19-37
Sacramento, CA 94244-2430
Telephone: 1-800-952-5253
Fax: 1-916-229-4410
TTY: 1-800-952-8349

If you want a State Hearing, you must ask for it within ninety (90) days from the date of receiving the letter for resolved grievance. You or your representative may speak at the State hearing or have someone else speak on your behalf, including a relative, friend or an attorney. You may also be able to get free legal help. You or your representative will be provided a list of Legal Services offices in Orange County at the time you file your grievance.