How to File a Grievance

Complaint

The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.

How to contact us when you are making a complaint about your medical care or your prescription drugs

You can make a complaint about us or one of our network providers or phamacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes.

There are two types of processes for handling problems and concerns:

  1. For some types of problems, you need to use the process for coverage decisions and appeals.
  2. For other types of problems, you need to use the process for making complaints.

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

Step 1: Contact us promptly – either by phone or in writing.

  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can contact Member Services at 1-866-333-3530. TTY users can call 711. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays.
  • If you do not wish to call, you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
  • Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
  • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we will give you an answer within 24 hours.

Mailing Address:
Vitality Health Plan of California
Member Services Department (Complaints)
18000 Studebaker Road, Suite 960
Cerritos, CA 90703

Fax Number: 1-866-207-6539

Click here to download the Grievance form (complaint).

Step 2: We look into your complaint and give you our answer.

  • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
  • To have a complaint reviewed, you should contact us promptly by phone or in writing. We must address your complaint as quickly as your case requires based on your health status, but no later than 30 days after we receive your complaint. We may extend the time frame by up to 14 calendar days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

You can submit a complaint about Vitality Choice directly to Medicare. To submit an online complaint to Medicare go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.


For more information on the drug coverage appeal process, you may refer to Chapter 9 Section 10 of the Evidence of Coverage (EOC).

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process. Go to “How to Appoint a Representative” page to find out more.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Vitality Member Services Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.