What is a complaint? This is also called a grievance.
A complaint, also known as a grievance, is a way of letting us know that you are not happy about your plan experience such as waiting too long in a doctor’s office, cleanliness of the doctor’s office, behavior by the pharmacist at the pharmacy, or the quality of care received from a doctor.
Another way to say “making a complaint”
is “filing a grievance.”
Another way to say “using the process for complaints”
is “using the process for filing a grievance.”
If you are not satisfied with the plan or our providers you may file a grievance. You need to file your grievance within 60 days of the occurrence. If you have a good reason for being late in filing a grievance, let us know and we will consider whether or not to extend the timeline for filing.
How to file a grievance
File a complaint/grievance by calling Customer Care at 1-855-562-8853. TTY users should call 711. We are open 8:00 a.m. to 8:00 p.m., Monday to Friday.
- Fax the grievance to us at 1-858-636-2256.
- Write a letter with your grievance and mail to:
Sharp Direct Advantage
Attention: Appeals and Grievance Department
8520 Tech Way, Ste. 201
San Diego, CA 92123
If you want someone else to send us a grievance on your behalf, you must send us an Appointment of Representative Form
or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the grievance.
If you or your provider has process or status questions about a grievance, please contact us at the telephone numbers listed above.
For information on how to obtain an aggregate number of grievances, appeals and exceptions filed with Sharp Health Plan or if you have a question about a status of an appeal, grievance or exception you requested, please call Customer Care at 1-855-562-8853 (TTY 711).
What happens when you file a grievance?
Grievances are generally responded to no more than 30 calendar days after the date the grievance is received. If more information is needed and the delay is in your best interest or if you ask us for more time, we may take up to 14 more calendar days (44 calendar days in total) to answer your grievance. If this extension is taken, we will notify you or your representative. Grievances filed because we denied your request for a “fast coverage decision” or a “fast appeal” will automatically be considered a “fast” grievance. If you have a “fast” grievance, we will give you an answer within 24 hours. If we don’t agree with part or all of your grievance we will let you know and include reasons for this response.
Submitting a complaint directly to Medicare
You can submit a complaint about Sharp Direct Advantage directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you want any information about our plan, like the number of appeals and grievances made by members, please call our Customer Care telephone number. We’re here to help.