Overview
Nivano Physicians is committed to providing members with accessible, fair, and timely grievance and appeals processes. Our procedures comply with federal Medicare regulations, California state requirements, and industry best practices to ensure member rights are protected and concerns are resolved promptly.
Legal Framework
This process is established in accordance with:
- 42 CFR Part 422, Subpart M – Medicare Advantage Appeals and Grievances
- 42 CFR Part 423, Subparts M and U – Part D Appeals and Grievances
- 42 CFR Part 438 – Medicaid Managed Care Appeals and Grievances
- California Knox-Keene Health Care Service Plan Act
- California Health and Safety Code Section 1368
- Department of Managed Health Care (DMHC) regulations
Definitions
Grievance
A grievance is any complaint or dispute expressing dissatisfaction about:
- Quality of care or services provided
- Aspects of interpersonal relationships such as rudeness, failure to respect privacy, or adequacy of time allocated
- Failure to respect member rights
- Aspects of the delivery of services, including the claims process
- The operation of the member appeals process itself
Appeal (Organization Determination)
An appeal is a request by a member for review of an adverse benefit determination, including:
- Denial, reduction, or termination of services
- Denial of payment for services
- Failure to provide services in a timely manner
- Failure to act within required timeframes
Expedited Appeals
Expedited appeals are available when applying standard timeframes could seriously jeopardize a member’s life, health, or ability to attain, maintain, or regain maximum function.
Member Rights
All Nivano Physicians members have the right to:
Grievance Rights
- File grievances without fear of discrimination or retaliation
- Receive assistance in filing grievances and appeals
- Receive written acknowledgment of grievances within required timeframes
- Obtain information about the grievance process in multiple languages
- Receive written resolution with explanation of findings
Appeal Rights
- Appeal adverse benefit determinations within required timeframes
- Request expedited appeals when standard timeframes could jeopardize health
- Continue receiving disputed services during the appeal process (in certain circumstances)
- Representation by healthcare providers, family members, or other advocates
- Access to case files and relevant medical records
Grievance Process
Filing a Grievance
Timeframes for Filing
- No time limit for filing most grievances
- Quality of care grievances: Must be filed within 180 days of the incident
- Service-related grievances: Should be filed within 60 days for optimal resolution
How to File
Oral Grievances (accepted for most issues):
- Phone: (916) 407-2000 ext 83000
- In-person: Visit any Nivano Physicians office
- Business hours: Monday-Friday, 8:00 AM – 5:00 PM PST
Written Grievances:
- Mail: Nivano Physicians Member Services
2554 Millcreek Dr. Suite 100
Sacramento, CA 95833 - Email: quality@nivanophysicians.com
- Online portal: Available through member login
- Fax: (916) 471-0332
Required Information
- Member name and identification number
- Description of the concern with specific details
- Dates and locations of relevant incidents
- Names of providers or staff involved
- Desired resolution or outcome
- Contact information for follow-up
Grievance Resolution Process
Acknowledgment
- Written acknowledgment within 5 business days of receipt
- Acknowledgment includes:
- Confirmation of grievance receipt
- Assigned case number for tracking
- Expected resolution timeframe
- Contact information for questions
Investigation
- Thorough review of all relevant information
- Medical record review for clinical issues
- Interview with relevant staff and providers
- Consultation with clinical experts when appropriate
- Review of applicable policies and procedures
Resolution
- Standard resolution: Within 30 calendar days
- Complex grievances: May require up to 30 additional days with member notification
- Written resolution provided explaining:
- Investigation findings
- Actions taken or planned
- Rationale for decision
- Right to external review if applicable
Quality of Care Grievances
Special Procedures
- Clinical review by qualified healthcare professionals
- Medical director involvement for complex cases
- External clinical consultation when indicated
- Coordination with quality improvement programs
Potential Outcomes
- Provider education and retraining
- Process improvements and policy changes
- Corrective action with individual providers
- Referral to licensing boards when appropriate
Appeals Process
Medicare Advantage Appeals
Organization Determinations
Standard Appeals:
- Filing deadline: 65 calendar days from adverse determination (updated from 60 days effective 1/1/2025)
- Resolution timeframe: 30 calendar days
- Extension: Up to 14 additional days if more information needed
Expedited Appeals:
- Available when: Standard timeframe could seriously jeopardize health
- Resolution timeframe: 72 hours
- Physician support: Healthcare provider must support expedited request
Required Forms and Notices
- Notice of Denial of Medical Coverage or Payment (NDMCP)
- Form CMS-10003-NDMCP
- Provided with all adverse determinations
- Includes specific reason for denial and appeal rights
- Notice of Medicare Non-Coverage (NOMNC)
- Form CMS-10123-NOMNC
- For services not covered by Medicare
- Advance notice when possible
- Detailed Explanation of Non-Coverage (DENC)
- Form CMS-10124-DENC
- Detailed explanation of coverage decision
- Information about appeal options
Levels of Appeal
Level 1: Organization Determination
- Nivano Physicians internal review
- 30 days for standard appeals
- 72 hours for expedited appeals
- Medical director review for clinical decisions
Level 2: Independent Review Entity (IRE)
- External review by CMS contractor
- 30 days for standard appeals
- 72 hours for expedited appeals
- Automatic forwarding if appeal upheld in member’s favor
Level 3: Administrative Law Judge (ALJ)
- Hearing before federal ALJ
- Amount in controversy: $180 minimum (2024)
- 90 days to request after IRE decision
- Evidence submission and testimony allowed
Level 4: Medicare Appeals Council
- Review of ALJ decisions
- 60 days to request review
- Written submission of arguments
- Discretionary review standard
Level 5: Federal District Court
- Judicial review for cases over $1,810 (2024)
- 60 days to file after Medicare Appeals Council
- Legal representation typically required
Part D Appeals
Coverage Determinations
- Formulary exceptions and prior authorizations
- Tiering exceptions for preferred cost-sharing
- Appeals of pharmacy rejections at point of sale
Exception Requests
- Formulary exceptions: For non-covered medications
- Tiering exceptions: For preferred tier placement
- Prior authorization exceptions: To bypass requirements
Medi-Cal Appeals (California-Specific)
Two-Step Process
- Health Plan Appeal
- 60 days to file with Nivano Physicians
- 30 days for plan to resolve
- Written decision with next steps
- State Fair Hearing
- 120 days to request from DHCS
- Administrative hearing with judge
- Final state-level decision
Independent Medical Review (IMR)
For Knox-Keene licensed plans:
- Available for medical necessity disputes
- External physician review of clinical decisions
- Binding decision on medical appropriateness
- No cost to members
California Resources
DHCS Ombudsman:
- Email: MMCDOmbudsmanOffice@dhcs.ca.gov
- Phone: 1-888-452-8609
- Assists with navigation and resolution
DMHC Help Center:
- Phone: 1-888-466-2219
- Online: www.dmhc.ca.gov
- Independent Medical Review requests
Member Support Services
Language Services
- Interpreter services available in all languages
- Translated materials in threshold languages
- TTY/TDD services for hearing impaired
- Large print and Braille materials upon request
Advocacy and Assistance
- Member services representatives to guide process
- Healthcare provider assistance with filing
- Family member representation allowed
- Legal advocate support permitted
Continuation of Benefits
During appeals process, members may continue receiving:
- Disputed services if appeal filed timely
- Prescription medications under certain circumstances
- Ongoing treatments pending resolution
Quality Assurance and Monitoring
Performance Metrics
- Grievance resolution times tracked and reported
- Appeal decision consistency monitored
- Member satisfaction with process measured
- Regulatory compliance audited regularly
Process Improvements
- Root cause analysis of recurring issues
- Policy updates based on outcomes
- Staff training on new procedures
- Technology enhancements for efficiency
Reporting Requirements
- CMS reporting of appeals and grievances data
- State agency reporting for Medi-Cal members
- Board reporting on trends and outcomes
- Quality committee review of clinical cases
Contact Information
Member Services
Phone: (916) 407-2000
Hours: Monday-Friday, 8:00 AM – 5:00 PM PST
TTY: 711
Email: customerservice@nivanophysicians.com
Appeals and Grievances Department
Mail: Nivano Physicians Appeals Department
2554 Millcreek Dr. Suite 100
Sacramento, CA 95833
Fax: (916) 471-0332
Email: quality@nivanophysicians.com
Emergency Contact
24/7 Nurse Line: (916) 407-2000
After-hours urgent appeals: customerservice@nivanophysicians.com
External Resources
Medicare:
- 1-800-MEDICARE (1-800-633-4227)
- TTY: 1-877-486-2048
- Website: www.medicare.gov
California Department of Health Care Services:
- Phone: 1-888-452-8609
- Website: www.dhcs.ca.gov
Department of Managed Health Care:
- Phone: 1-888-466-2219
- Website: www.dmhc.ca.gov
This Grievance and Appeals Process ensures that all members have access to fair, timely, and comprehensive review of their concerns and benefit determinations.
Document Version: 1.0
Effective Date: August 7, 2025
Next Review Date: August 7, 2026