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How to file a Grievance or Appeal

All members have the right to appeal any claim denial or treatment authorization. The Evidence of Coverage (see chapter 8 "Your Rights and Responsibilities" in the Evidence of Coverage for Grievance, Coverage Determination (including exceptions, appeals, and organizational Determination) instructs members to call or write Inter Valley Health Plan (Inter Valley Health Plan, Appeals & Grievance Department, P. O. Box 6002, Pomona, CA 91769-6002)  should they wish to dispute a medical or payment decision made by their physician, Provider Group, or Inter Valley Health Plan.

Service To Seniors (HMO),  Desert Preferred Choice (HMO) - 

2022 Evidence of Coverage (EOC)     

Vitality Plus (HMO) -

2022 Evidence of Coverage (EOC)

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 time frame 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, 8 a.m. to 8 p.m.

Instructions on Appointment of Representative Form:
A party may appoint any individual, including an attorney, to act as his/her representative in dealings with the contractor. Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal. (See §270.1.10 for information on disclosing information to third parties) The appointment of a representative is valid for one year from the date signed by both the party and the appointed representative.
NOTE: A representative must sign the appointment within 30 calendar days of the party’s signature. The appointment remains valid for any subsequent levels of appeal on the item/service in question unless the beneficiary specifically withdraws the representative’s authority. (See §270.1.3.) New appeals may be initiated by the representative within the 1-year time frame. To initiate a new appeal within the 1-year time frame, the representative must file a copy of the CMS-1696, or other conforming written instrument, with the appeal request. In order for the appointment to be valid, it must be signed and dated by the beneficiary.

Appointment of Representative Form (by clicking this link you will be redirected away from Inter Valley Health Plan's website)

Who May Be a Representative:
Any individual may be appointed to act as a representative unless he/she is disqualified, suspended, or otherwise prohibited by law from acting as a representative in proceedings before DHHS, or in entitlement appeals, before SSA. A contractor should not accept an appointment of representative if it has evidence that the appointment of representative should not be honored. It should notify the party attempting to be represented and the individual attempting to represent the party that the appointment will not be honored. A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is released only to the individual so named.

A provider or supplier who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative of the beneficiary. To act as the beneficiary’s representative, the provider or supplier must meet the criteria set forth in this section. If the requestor is the beneficiary’s legal guardian, surrogate decision-maker for an incapacitated beneficiary, or otherwise authorized under State law, no appointment is necessary, and the requestor is defined as the authorized representative.

How to Make and Revoke an Appointment
The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument (see subsection B below, for required elements of written instruments). A party may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or other party signs in order for the appointment to be valid. (See subsection A, below, for exceptions.) By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.

A. Completing a valid Appointment of Representative (CMS-1696)
The CMS-1696 is available for the convenience of the beneficiary or any other party to use when appointing a representative. Following are instructions for completing the form.
1. The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare number must be provided.
2. Completing Section I – “Appointment of Representative”-A specific individual must be named to act as representative in the first line of this section; a party may not appoint an organization or group to act as representative. The signature, address, and phone number of the party making the appointment must be completed, and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for, or acting as an agent of, the provider or supplier must sign and complete this section.
3. Completing Section II – “Acceptance of Appointment”- The name of the individual appointed as representative must always be completed, and his/her relationship to the party entered. The individual being appointed then signs and completes the rest of this section.
4. Completing Section III – “Waiver of Fee for Representation”- This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal.
5. Completing Section IV – “Waiver of Payment for Items or Services at Issue” – This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Act.

If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the defect is cured, the prospective appointed representative lacks the authority to act on behalf of the party, and is not entitled to obtain or receive any information related to the appeal, including the appeal decision. The adjudicator shall not dismiss the appeal request because the appointment of representative is not valid.

Where to send a Appointment of Representative form:
The signed Appointment of Representative should be forwarded via mail only to:

Attn: Grievance & Appeals
Inter Valley Health Plan
300 South Park Avenue
Pomona, CA. 91769-6002

Telephone:   1-909-623-6333 or 1-800-251-8191
TTY Devices:  711
Fax:     1-909-620-8092


Where to send a Grievance, Appeal, Organization Determination, or Coverage Determination:
Inter Valley Health Plan
Appeals & Grievance Department
P. O. Box 6002
Pomona, CA 91769-6002

300 South Park Ave
Pomona, CA 91769

Telephone:   1-909-623-6333 or 1-800-251-8191
TTY Devices:  711
Fax:     1-909-620-8092

Appeals and Grievances forms:

Medicare Advantage Plan Member Appeals & Grievance

Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination of Medicare Prescription Drug Denial

Medicare Complaint Form (by clicking this link, you will be redirected away from Inter Valley Health Plan's website.)


Updated 12/29/2021

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