Nivano Physicians, Inc.
Effective Date: August 7, 2025
Last Updated: March 12, 2026
Version: 2.0
Overview
Nivano Physicians is committed to providing members with accessible, fair, and timely processes for addressing complaints and appealing benefit decisions. Our grievance and appeals procedures comply with federal Medicare regulations, California state requirements, and the Knox-Keene Health Care Service Plan Act.
Regulatory Framework
| Authority | Coverage |
|---|---|
| 42 C.F.R. Part 422, Subpart M | Medicare Advantage appeals and grievances |
| 42 C.F.R. Part 423, Subparts M and U | Part D appeals and grievances |
| 42 C.F.R. Part 438 | Medicaid managed care appeals and grievances |
| California Knox-Keene Health Care Service Plan Act | State plan requirements |
| California Health and Safety Code § 1368 | Member grievance rights |
| DMHC regulations | Independent Medical Review and oversight |
Definitions
A grievance is any complaint or dispute expressing dissatisfaction about quality of care, interpersonal conduct (rudeness, failure to respect privacy), failure to respect member rights, the delivery of services or the claims process, or the operation of the appeals process itself.
An appeal (also called an organization determination) is a formal request for review of an adverse benefit determination — including denial, reduction, or termination of services; denial of payment; or failure to act within required timeframes.
An expedited appeal is available when applying the standard review timeframe could seriously jeopardize a member’s life, health, or ability to maintain or regain maximum function.
Member Rights
All Nivano Physicians members have the right to file grievances and appeals without fear of discrimination or retaliation, receive assistance with the filing process, receive written acknowledgment and written resolution within required timeframes, obtain information about the process in multiple languages, be represented by a healthcare provider, family member, or other advocate, access case files and relevant medical records, and — for appeals — continue receiving disputed services during the review process in certain circumstances.
Grievance Process
How to File a Grievance
Grievances may be filed orally or in writing at any time (quality of care grievances must be filed within 180 days of the incident).
Oral or phone grievances:
Phone: (916) 407-2000, ext. 83000
Hours: Monday–Friday, 8:00 a.m. – 5:00 p.m. PST
Written grievances:
Email: quality@nivanophysicians.com
Fax: (916) 471-0332
Mail: Nivano Physicians Member Services, 2554 Millcreek Dr., Suite 100, Sacramento, CA 95833
Online: Available through the member portal
When filing, please provide your name and member ID, a description of the concern with relevant dates and locations, names of providers or staff involved, your desired resolution, and your contact information.
Resolution Timeframes
| Type | Timeframe |
|---|---|
| Written acknowledgment | Within 5 business days of receipt |
| Standard grievance resolution | Within 30 calendar days |
| Complex grievance | Up to 30 additional days with member notification |
| Quality of care grievance | Clinical review by qualified professionals |
All resolutions are provided in writing, including the investigation findings, actions taken, rationale for the decision, and any right to external review.
Medicare Advantage Appeals
Filing Deadlines and Timeframes
| Appeal Type | Filing Deadline | Resolution Timeframe |
|---|---|---|
| Standard appeal | 65 calendar days from adverse determination | 30 calendar days |
| Expedited appeal | At any time when health could be jeopardized | 72 hours |
| Standard extension | N/A | Up to 14 additional days if more information needed |
Required Notices
- Notice of Denial of Medical Coverage or Payment (NDMCP) — Form CMS-10003, provided with all adverse determinations
- Notice of Medicare Non-Coverage (NOMNC) — Form CMS-10123, for services not covered by Medicare
- Detailed Explanation of Non-Coverage (DENC) — Form CMS-10124, with detailed coverage decision rationale and appeal information
Five Levels of Medicare Appeal
Level 1 — Organization Determination (Nivano Physicians)
Internal review by Nivano Physicians, with medical director involvement for clinical decisions. Standard: 30 days. Expedited: 72 hours.
Level 2 — Independent Review Entity (IRE)
External review by a CMS-contracted IRE. If the Level 1 appeal is upheld in the member’s favor, the case is automatically forwarded. Standard: 30 days. Expedited: 72 hours.
Level 3 — Administrative Law Judge (ALJ)
Federal ALJ hearing, available if the amount in controversy meets the minimum threshold ($180 in 2024). Must be requested within 90 days of the IRE decision.
Level 4 — Medicare Appeals Council
Review of ALJ decisions. Must be requested within 60 days of the ALJ decision. Written submission of arguments.
Level 5 — Federal District Court
Judicial review for cases meeting the threshold ($1,810 in 2024). Must be filed within 60 days of the Medicare Appeals Council decision.
Part D (Prescription Drug) Appeals
Part D appeals cover coverage determination denials for formulary exceptions, prior authorizations, and tiering exception requests. Members may request formulary exceptions for non-covered medications, tiering exceptions for preferred cost-sharing, or prior authorization exceptions. Standard and expedited timeframes mirror Medicare Advantage requirements above.
Medi-Cal Appeals
Two-Step Process
Step 1 — Health Plan Appeal
File within 60 days of the adverse determination. The plan has 30 days to resolve the appeal and provide a written decision. Contact: quality@nivanophysicians.com or (916) 407-2000.
Step 2 — State Fair Hearing
Request within 120 days of the plan’s decision through the California Department of Social Services.
Phone: 1-800-743-8525 | Website: cdss.ca.gov
Independent Medical Review (IMR)
For Knox-Keene licensed plans, members may request IMR for medical necessity disputes. IMR provides external physician review of clinical decisions, is available at no cost to members, and results in a binding decision on medical appropriateness.
DMHC Help Center: 1-888-466-2219 | dmhc.ca.gov
DHCS Medi-Cal Ombudsman: 1-888-452-8609 | MMCDOmbudsmanOffice@dhcs.ca.gov
Member Support Services
Language services — Interpreter services are available in all languages. Materials are provided in California’s 15 threshold languages upon request. TTY/TDD services and large print or Braille materials are also available.
Continuation of benefits — Members may be entitled to continue receiving disputed services during an appeal if the appeal is filed timely. Contact Member Services to confirm eligibility for benefit continuation in your specific situation.
Contact Information
Member Services
Phone: (916) 407-2000
Toll Free: (844) 889-2273
Appeals and Grievances Department
Email: quality@nivanophysicians.com
Fax: (916) 471-0332
Mail: Nivano Physicians Appeals Department, 2554 Millcreek Dr., Suite 100, Sacramento, CA 95833
External Resources
| Resource | Contact | ||
|---|---|---|---|
| Medicare | 1-800-MEDICARE (1-800-633-4227) | TTY: 1-877-486-2048 | medicare.gov |
| California DHCS | 1-888-452-8609 | dhcs.ca.gov | |
| DMHC Help Center | 1-888-466-2219 | dmhc.ca.gov | |
| CDSS Fair Hearings | 1-800-743-8525 | cdss.ca.gov |
Policy Review
This document is reviewed annually and updated to reflect current federal and state regulations, including CMS annual updates to appeal thresholds, timeframes, and required notice forms. The next scheduled review is August 7, 2026.
This document was last updated on March 12, 2026.