About the Complaint Data Reports
The Office of the Patient Advocate is tasked with producing an annual report on health care complaint data and other consumer assistance information. View the related reporting requirements outlined in California Health and Safety Code Section 136000.
Data Collection and Analysis
For the annual reports, OPA collects and analyzes descriptive information about the state's health care consumer assistance as well as quantitative records on complaints closed during a calendar year. Four state reporting entities - the Department of Managed Health Care (DMHC) Department of Health Care Services (DHCS), California Department of Insurance (CDI), and Covered California - are statutorily required to submit non-aggregated complaint data to OPA.
The type of complaint records that were submitted include:
- DMHC - Standard Complaints, Independent Medical Reviews, Quick Resolutions, and Urgent Nurse Complaints
- DHCS - State Fair Hearings [conducted by the California Department of Social Services (CDSS)]
- CDI - Standard Complaints and Independent Medical Reviews
- Covered California - State Fair Hearings (conducted by CDSS), Informal State Fair Hearings
View the detailed methodology for the 2016 Complaint Data Report.
The detailed methodology for prior year's reports can be found in the Background and Methodology sections of those reports.
Click here for prior years' reports
Complaint Data Definitions
OPA is dedicated to standardizing complaint reporting. Many of the terms used in the complaint data reports are based on complaint categories defined by the National Association of Insurance Commissioners. OPA worked with the state reporting entities to map their complaints to standardized categories and add or adjust categories as needed.
OPA relied on two primary data distinctions for reporting on consumer assistance cases.
- Complaint: Includes written or oral complaints, grievances, appeals, independent medical reviews, hearings, and similar processes to resolve a consumer problem or dispute.
- Inquiry: A request for assistance when a consumer requires only information on a jurisdictional topic or education on a non-jurisdictional topic and a referral to another entity.
Other Complaint Data Resources
The following state websites have reports and other information about health care coverage complaints in California.
Department of Managed Health Care
Department of Insurance
Department of Health Care Services
Department of Social Services
The following websites have reports and other information about health care coverage complaints nationally.
National Association of Insurance Commissioners