HealthWorx HMO

Problems & Complaints

If you are dissatisfied with your medical care or the service provided by HPSM or your doctor's office, we want to address and resolve it to your satisfaction. Our grievance and appeals process allows us to do this as quickly as possible.

Expressing concerns or filing a complaint will not affect your benefits in any way. Your provider (doctor) also cannot discriminate against you because you file a complaint.

How to file a complaint

First, call Member Services; they will try to resolve your concern over the phone. If we do not resolve your complaint to your satisfaction within 24 hours, the Grievance and Appeals Unit will start a formal process to reach a solution.

Grievance and Appeals

There are two types of complaints, a grievance and an appeal

1. File a grievance if you are dissatisfied about the medical services or customer service you received from HPSM or a provider. You must file the grievance within 180 days (6 months) of the event.
   
2. File an appeal if you want HPSM to reconsider a decision to deny coverage for a service or item you or your doctor requested. You must file the appeal within 180 days (6 months) of the denial.

There are four ways you can file a grievance

1. Online: Fill out and submit our online confidential member complaint form.
2. By phone: Call Member Services at 1-800-750-4776 (toll-free) or 650-616-2133.
3. In writing: Download and complete our printable member complaint form, then fax it to 650-829-2002 or mail it to the address printed on the form.
4. In person: Visit our office to speak face-to-face with a representative about your grievance.

There are two ways you can file an appeal

1. By phone: Call a Member Services Representative at 1-800-750-4776 (toll-free) or 650-616-2133.
2. In person: Visit our office to speak face-to-face with a representative about your appeal.

Complaints about emergency situations

If your complaint involves an imminent and serious threat to your health (including but not limited to severe pain, potential loss of life, limb or major bodily function), you or your provider may request an expedited (fast-tracked) review. If your complaint qualifies, we will resolve it within three days of receipt.

After you file a complaint

Within five business days of receiving your complaint, an HPSM Grievance and Appeals Coordinator will call you to discuss your complaint and review HPSM's complaint process. We will resolve your complaint within 30 days and send you a letter explaining our decision. To ask about the status of an existing complaint, call our Grievance and Appeals Unit.

Any services that were authorized will continue to be provided until your complaint is resolved.