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All members have the right to appeal any claim denial or treatment authorization. The Evidence of Coverage instructs members to call or write Inter Valley Health Plan should they wish to dispute a medical or payment decision made by their physician, Provider Group, or Inter Valley Health Plan.
The following procedures are for Appeals and Grievances:
Standard Appeal – An "appeal" is when a member wants the Plan to reconsider and change a decision that has been made about what services are covered for the member or what we will pay for a service.
Expedited(72-hour) Appeal – An "expedited appeal" is a time-sensitive situation. A "time–sensitive" situation is a situation where waiting for a decision to be made within the timeframe of a standard decision making process could seriously jeopardize the member's life, health, or ability to regain maximum function. Services involving an imminent and serious threat to the health of the member, including but not limited to, severe pain, potential loss of life, limb, or major body function.
If you disagree with our decision to not give you a "fast appeal," or if we take an extension on our initial decision or appeal... you have the right to ask for a "fast grievance."
Grievance – A "grievance" is a complaint regarding any other problems a member may have with the Plan or one of our providers. For example, issues regarding quality of care, waiting times for appointments or in the waiting room, cleanliness or condition of the doctor's office and the way doctors or others behave.
A member may appoint an individual to act as his/her representative to file an appeal. If a member designates another individual to file an appeal on his/her behalf, the member must provide a statement to Inter Valley Health Plan that is dated and signed by the member and his/her representative. The statement must accompany the appeal.
A member or his/her authorized representative may contact the Plan regarding an appeal or grievance by telephone, letter, fax, or visit Inter Valley Health Plan, Monday through Friday, 7:30a.m. to 8 p.m.:
Telephone: 1-909-623-6333 or 1-800-251-8191
TTY/TDD Devices: 1-800-505-7150
Fax: 1-909-620-8092
Write:
Inter Valley Health Plan
Appeals & Grievance Department
P. O. Box 6002
Pomona, CA 91769-6002
Visit:
300 South Park Ave
Pomona, CA 91769
Click here for "Appeals and Grievances" forms.
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