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Home > Complaint Stats-2015-DHCS

Complaints Reported by the Department of Health Care Services for 2015

The California Department of Health Care Services oversees the Medi-Cal program. State Fair Hearings conducted by the Department of Social Services are an avenue for Medi-Cal applicants and members to address complaints about the program. 

The following table outlines State Fair Hearings reported by the Department of Health Care Services for OPA's annual Complaint Data Report.

2015 State Fair Hearings on Medi-Cal
(conducted by the Department of Social Services)
Most Common Reasons for Hearings in 2015 Medi-Cal (Managed Care and Fee for Service): 
  • Pharmacy Benefits (40%)
  • Quality of Care (25%)
  • Dis-Enrollment and Enrollment Issues (22%)
  • Provider Billing or Reimbursement Issues (4%)
  • Medical Necessity Denial (4%)
  • Scope of Benefits (82%)
  • Medical Necessity Denial (12%)
  • Claim Denial (6%)
Mental health:
  • Denied Services (46%)
  • Unknown (23%)​
Most Common Results from Hearings in 2015
  • Complaint Withdrawn (48%)
  • Health Plan Position Upheld (23%)
  • No Action Required (18%)
  • Health Plan in Compliance (5%)
  • Health Plan Position Overturned (3%)
Number of Days the Hearing Process Took in 2015 Between 0-200 days