https://www.anthem.com 1-855-679-8774 (TTY: 711)
https://www.blueshieldca.com (888) 568-3560
https://www.scanhealthplan.com 1+877-452-5898 (TTY: 711)
https://www.humana.com/medicare 1+855-401-9567 (TTY: 711)
https://shop.anthem.com/medicare/ca 805-573-9254
Appeals & Grievances
We are committed to ensuring our members receive high-quality care and service. If you are dissatisfied with your care, services, or a coverage decision, you have the right to file a grievance or appeal through your health plan.
Quality of Care Complaints (Grievances)
If you’re unhappy with the quality of care or services—not related to a denied treatment—you or someone you authorize may file a grievance with your health plan. This process allows you to report issues such as:
Please refer to your health plan’s member materials for instructions on how to submit a grievance.
Appealing a Denied Service
If your health plan denies a service and you disagree with the decision, you have the right to appeal. Appeals must be submitted within 60 days of the denial. You can file:
Appeals can be submitted verbally or in writing. Be sure to include your denial notice and a brief explanation.
Expedited Appeals
If your health is at serious risk due to a delay, you may request an expedited appeal. Your health plan will evaluate your condition and respond within 72 hours. If the decision is not in your favor, you may request a hearing with the Appeals and Grievance Committee, which will be scheduled within 10 working days.
Below are the processes and contact details for each contracted health plan:
Anthem Blue Cross
Blue Shield of California
Humana
SCAN Health Plan
Need Help?
If you need assistance filing a grievance or appeal, please contact your health plan directly or reach out to our Member Services team. We’re here to support you through the process.
You may also get help from the California Department of Managed Health Care (DMHC), if your grievance:
You may contact the DMHC Help Center at:
The DMHC oversees health plans in California and ensures your rights are protected.
Notice of Privacy Practices
Your Privacy Matters
This Notice describes how your medical information may be used and disclosed, and how you can access this information. Please review it carefully.
Our Legal Duties
How We May Use and Disclose Your PHI
We may use or disclose your PHI for:
Other permitted uses include:
We will not use or disclose your PHI for marketing, sale of information, or other purposes without your written authorization.
Your Rights
You have the right to:
California-Specific Protections
Under California law:
Website Privacy
Our website may collect limited electronically collected personal information (e.g., IP address, browser type) for analytics and performance improvements. No PHI is collected through the website.
Contact Us
If you have questions or concerns about this Notice or your privacy rights, please contact:
Rincon Health Network Member Services
Phone: (805) 840-2524
Toll Free: (844) 582-1307
E-Mail: [email protected]
Members Rights & Responsibilities
Our Members have the following Responsibilities:
Our Members have a Right to:
HIPAA and Patient Privacy
The federal Health Insurance Portability and Accountability Act (HIPAA) and California law
give you rights to:
OB/Gyn
Female patients of all ages can receive routine and ongoing care from one of our OB/GYN specialists—no referral needed. You’re welcome to choose a provider from our OB/GYN directory or ask your PCP for a recommendation.
If you are pregnant or become pregnant, your OB/GYN will support and care for you throughout your pregnancy and delivery.
Specialty Care
Pre-Authorization Requirements
When your PCP or specialist determines that additional care is needed, a pre-authorization, also known as a referral, request will be submitted for review. Our Authorizations team, in collaboration with a Physician Reviewer, will assess the request based on your medical condition, treatment needs, and your health plan’s coverage, including any applicable exclusions or limitations. Authorization decisions are guided by nationally recognized, evidence-based criteria. Please note that services not covered by your health plan cannot be approved.
You typically need pre-authorization for:
Specialist visits (e.g., cardiology, dermatology) | Home Health Services |
Surgeries & procedures | Non-Emergency Hospital Admissions |
Advanced Imaging (e.g., MRI, CT scans) | Out-of-network Service |
Durable Medical Equipment (DME) |
Your physician will submit your pre-authorization request as Routine, Urgent or Stat, which are used to prioritize medical service requests based on clinical urgency.
You’ll receive written notification once a decision has been made regarding your prior authorization request. If you have any questions about the decision or would like more details about the review process, our Member Services team is here to help—please don’t hesitate to reach out!
805-840-2524 or toll free 844-582-1307
Your medical services are coordinated and covered directly through Rincon or your health plan. You’re only responsible for your co-pays, co-insurance, applicable deductibles, and services not covered under your specific plan benefits.
If you happen to receive a bill from a physician or outpatient provider, don’t worry—just reach out to Rincon’s Member Services team for assistance.
Our Commitment to Fairness in Medical Authorization
At Rincon Health Network, we believe everyone deserves equal access to the care they need. When reviewing medical authorization requests, we follow strict policies to ensure fairness and non-discrimination for all patients—regardless of race, ethnicity, gender identity, sexual orientation, age, disability, veteran status, or any other protected characteristic.
We’re committed to creating an inclusive and respectful healthcare experience. If you ever feel that you’ve been treated unfairly during the authorization process, or if you have questions about how decisions are made, please contact our Member Services team. We’re here to support you.
Quest Diagnostics for Laboratory Testing
Rincon Health Network partners exclusively with Quest Diagnostics for routine laboratory testing. Your physician can submit lab orders directly to Quest—no prior authorization is required for most routine services, making the process fast and convenient.
Quest offers numerous locations throughout Ventura County, along with flexible scheduling options:
To find a nearby location or schedule your lab visit, call (866) 697-8378 or visit www.QuestDiagnostics.com.
Rolling Oaks Radiology for Imaging
Rincon Health Network partners exclusively with Rolling Oaks Radiology, a trusted member of the RadNetfamily, to provide high-quality imaging services for our patients.
Your physician can easily request routine X-rays through RadNet—no prior authorization is needed for most standard imaging. For advanced procedures such as CT scans or MRIs, your provider will handle any necessary authorizations to ensure a smooth experience.
With multiple locations across Ventura County, Rolling Oaks Radiology offers:
To find a location near you or to book an appointment, call (805) 778-1513 or visit www.RollingOaksRadiology.com