Grievances, Complaints & Appeals
All PCAC-Unilogic Health Care Management, MSO members have the right to file a grievance, complaint, or an appeal on any decision.
A grievance is a written or verbal expression of a member’s dissatisfaction with the care or services provided and may be used to request a review of a complaint or inquiry that has not been resolved to the member’s satisfaction. Grievances should be submitted to the member’s assigned health plan online, by phone, or in writing.
A complaint (or inquiry) is a member’s written or verbal request for information or assistance, or an expression of concern about an issue. A complaint can become a grievance. Complaints should be submitted to the member’s assigned health plan online, by phone, or in writing.
An appeal is a written or verbal request to reconsider the initial determination of a denied healthcare service or claim. Appeals can be requested by submitting a written or verbal notification to the members assigned health plan to appeal any decision that the member believes is unfair or unjust.
Members have the right to file a discrimination complaint with the United States Department of Health and Human Services Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex electronically through the Office for Civil Rights Complaint Portal or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Complaint forms are available at the U.S. Department of Health and Human Services website. Complaints filed with the U.S. Department of Health and Human Services; Office for Civil Rights must be filed within 180 days of the date of the alleged discrimination.
Health Plan Contact Information
Check ID Card
Decision Making Guidelines for Treatment Requests & Referrals
PCAC-Unilogic Health Care Management MSO utilizes evidence-based guidelines when making
decisions regarding referral requests for services. As a member, you may ask for free copies of
all information used to make a decision regarding your requested service. If you would like a
copy of the actual benefit provision, guidelines protocol, or criteria that we based our decision
on, you may call: (562) 602-1563
Main Criteria sets used by PCAC-Unilogic Health Care Management MSO Include:
CMS.Gov National Coverage Determinations (NCD) Guidelines
CMS.Gov Local Coverage Determinations (LCD) Guidelines
CMS Medicare Benefit Manuals
MCG Care Guidelines for Evidence Based Medicine
Contracted Health Plan Guidelines
Interpretation & Translation
Limited English Proficient or LEP Enrollee: A person who has an inability or a limited ability to speak, read, write, or understand the English language at a level that permits that individual to interact effectively with health care providers or plan employees.
You have the right to no-cost interpreting services, as well as American Sign Language. You can get these services 24 hours a day, seven days a week. You can request interpreting or translation services, information in your language or another format such as large print or audio, or auxiliary aids and services by calling the assigned health plan phone number listed on the back of your health insurance plan ID card. You can also ask your AHN provider’s office for assistance in doing this.
Members who are deaf or hard of hearing can access TDD/TYY Services directly by calling California Relay Service (CRS) by dialing 711 24 hours a day, 7 days a week, including holidays.
Complaints Related to Language Assistance Services
You can file a complaint at any time with your Health Plan if:
You feel that you were denied services because you do not speak English
You cannot get an interpreter
You have a complaint about the interpreter
You cannot get information in your language or format
Your cultural needs are not met