Questions? MemorialCare Select Health Plan is ready to take your call and will get you to the right individuals to answer your questions.
Phone: (844) 805-8700 TTY/TDD: 711
Evidence of Coverage and Disclosure
Member Rights and Responsibilities
Log in to MyChart for 24/7 member support and information, including the ability to:
- View Details on your Benefits
- File a Grievance
- Change your PCP
- Order an ID card
- Access Test Results
- Communicate with your doctor
- Access your test results
To log on to the Member Portal, please click here.
Grievance And Appeals
How to File a Grievance
MemorialCare Select Health Plan has a formal process for reviewing member grievances and appeals. This process provides a uniform and equitable treatment of your grievance/appeal and a prompt response. MemorialCare Select Health Plan shall ensure that all enrollees have access to and can fully participate in the grievance system by providing assistance for those with limited English proficiency or with visual or other communicative impairment. Such assistance shall include, but is not be limited to, translation of grievance procedures, forms and plan responses to grievances, as well as access to interpreters, telephone relay systems and other devices that aid disabled individuals to communicate.
A grievance is a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration, or appeal made by a member or the member’s representative. When the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance. Members have up to 180 calendar days from the date of an incident or dispute, or from the date the member receives a denial letter, to submit a grievance or appeal to MemorialCare Select Health Plan.
You may file a grievance in one of the following ways:
- Telephone - Call the Member Services phone number on your MemorialCare Select Health Plan ID card or 1 (844) 805-8700.
- Online - Submit your grievance online by logging into MyChart and filling out the GRIEVANCE FORM. Please attach any available documents. You can also fill out the GRIEVANCE FORM here.
- Mail - This form is currently being updated, please check back later.
Mail to:MemorialCare Select Health Plan, Attn: Member Grievance 17360 Brookhurst Street Fountain Valley, CA 92708
Information you provide us becomes part of the permanent grievance record. You will be sent an acknowledgement within 5 calendar days and a response within 30 calendar days of us receiving this form or your call.
Independent Medical Review
MemorialCare Select Health Plan is responsible for the correspondence, resolution and forwarding your case to Independent Medical Review if needed.
You Can Apply for an IMR if your Health Plan:
- Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary
- Will not cover an experimental or investigational treatment for a serious medical condition
- Will not pay for emergency or urgent medical services that you have already received
Click below to download an Independent Medical Review form.
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-844-805-8700) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.
Further Appeal Rights
If you are dissatisfied with your Primary Health Plan’s answer, you may be able to pursue one or more of the following appeal processes, depending on your situation and the appeal information contained in your Primary Health Plan’s Evidence of Coverage. If you need assistance please contact Member Services at the number on the back of your Primary Health Plan’s member ID card.
- File a complaint with the Department of Managed Health Care (DMHC) provided that your health coverage is governed by them. Click on the following link to be directed to the DMHC web site http://www.dmhc.ca.gov/. If your health coverage is not governed by the DMHC, it may be governed by the Department of Insurance. Please contact your Primary Health Plan’s Member Services if you are not sure which entity governs your health coverage. Your Primary Health Plan’s Member Services number is on the back of your Primary Health Plan’s member ID card.
- Request Independent Medical Review. Independent Medical Review is available for decisions to deny payment on the basis that the services are not medically necessary or that they are considered investigational or experimental. If your grievance involves a denial of health care service, information on the Independent Medical Review process will be provided in the letters sent to you by your Primary Health Plan.
- Have your case reviewed in an administrative hearing if you are a Medicare beneficiary or a MediCal member. Those rights are identified in your Primary Health Plan’s Evidence of Coverage.
- Seek legal remedies in a court of law.
Evidence of Coverage and Disclosure
The Evidence of Coverage and Disclosure Form provides detailed information about your benefits and how, when and where you access covered health care services. Please see the Evidence of Coverage and Disclosure Form below:
If you have any questions that are not answered by the Evidence of Coverage and Disclosure Form, please Contact Us.
For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-844-805-8700 to request a copy.
Member Rights and Responsibilities
As a MemorialCare Select Health Plan member, you have the right to...
Respectful and courteous treatment. You have the right to be treated with respect, dignity and courtesy from your health plan’s providers and staff. You have the right to be free from retaliation or force of any kind when making decisions about your care.
Privacy and confidentiality. You have the right to have a private relationship with your provider and to have your medical record kept confidential. You also have the right to receive a copy of, amend, and request corrections to your medical record. If you are a minor, you have the right to certain services that do not need your parents' okay.
Choice and involvement in your care. You have the right to receive information about your health plan, its services, its doctors and other providers. You have the right to choose your primary care provider (PCP) from the doctors and clinics listed in your health plan’s provider directory. You also have the right to get appointments within a reasonable amount of time. You have the right to talk with your doctor about any care your doctor provides or recommends, discuss all treatment options, and participate in making decisions about your care. You have the right to a second opinion. You have the right to talk candidly to your doctor about appropriate or medically necessary treatment options for your condition, regardless of the cost or what your benefits are. You have the right to information about treatment regardless of the cost or what your benefits are. You have the right to decline treatment. You have a right to decide in advance how you want to be cared for in case you get a life- threatening illness or injury.
Receive timely customer service. You have the right to wait no more than 10 minutes to speak to a customer service representative during MemorialCare Select Health Plan's normal business hours.
Voice your concerns. You have the right to complain about MemorialCare Select Health Plan, the providers we work with, and the care you get without fear of losing your benefits. MemorialCare Select Health Plan will help you with the process. If you don’t agree with a decision, you have the right to appeal, which is to ask for a review of the decision.
Service outside of your health plan’s provider network. You have the right to receive emergency or urgent services as well as family planning and sexually transmitted disease services outside of your health plan’s network. You have the right to receive emergency treatment whenever and wherever you need it.
Service and information in your language. You have the right to request an interpreter at no charge instead of using a family member or friend to interpret for you. You should not use children to interpret for you. You have the right to get the Member Handbook and other information in another language or format (such as audio, large print or Braille).
Know your rights. You have the right to receive information about your rights and responsibilities. You have the right to make recommendations about these rights and responsibilities.
As a MemorialCare Select Health Plan member, you have the responsibility to...
Act courteously and respectfully. You are responsible for treating your doctor and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor’s office at least 24 hours before your visit to cancel or reschedule.
Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your providers and to MemorialCare Select Health Plan. You are responsible for getting regular checkups and telling your doctor about health problems before they become serious.
Follow your doctor’s advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
Use the Emergency Room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor.
Report wrong-doing. You are responsible for reporting health care fraud or wrongdoing to MemorialCare Select Health Plan. You can do this without giving your name by calling the 24-Hour Ethics Hotline at (888) 933-9044 and leaving a message or sending an e-mail to firstname.lastname@example.org.
Notice of Privacy Practices
MemorialCare Select Health Plan values your privacy and outlines the ways that we use and disclose medical information about you in our Notice of Privacy Practices document found below: