Appeals and Grievances

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Appeals and Grievances

There may be times when members have a complaint or disagree with a decision that was made by Jade Health Care Medical Group or by a contracted provider about benefit coverage, services or non-payment of care/service. Members may also express concerns about an experience they had with some aspect of their care/service. In these instances, members, or their designated representative (who may be their physician acting on their behalf) have the right to file an appeal and/or a grievance.

An appeal is a complaint about a coverage decision, including a denial of payment for a service received, or a denial in providing a service a member feels they are entitled to as a Jade Health Care Medical Group member. Coverage decisions that may be appealed include a denial of payment for any health care services they received, or a denial of a service that they believe should have been arranged for, furnished, or paid for by Jade Health Care Medical Group.

A grievance is a complaint about a problem a member observes or experiences, including complaints about the quality of services that they receive, complaints regarding such issues as office waiting times, physician behavior, adequacy of facilities, or other similar concerns.

How to File a Complaint – Appeal or Grievance
Contact the Jade Health Care Medical Group Member Services Department for assistance in filing a verbal or written grievance or appeal. The Member Services staff can assist members or a provider acting on their behalf in filing a grievance or appeal. We have a complaint form, which can be used to file a grievance or an appeal which is available from Member Services, or you may download and print the form from our website, or you can file a complaint online using our secure online complaint form. However, you do not have to use our complaint form to file a grievance or appeal; you may call Member Services, send us a letter or fax, or come to our office. With or without the form, please provide a brief explanation of the issue and submit it in one of the following ways:

Member Compliant Form (PDF)

Telephone: 1-415-834-2118 or (TTY) 1-877-681- 8888
Fax: 1-415-397-2129
In Person:
Jade Health Care Medical Group
Member Services Dept
827 Pacific Ave.
San Francisco, CA 94133