How to File a Complaint
You have the right to file a complaint with your health plan if you have a problem getting the health care services you need. You can also file an external appeal with the agency that oversees your health plan.
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File a complaint or grievance with your plan
You have a right to file a complaint with your health plan. A complaint is also called a grievance. You might want to try talking to your doctor about the problem first. To file a complaint:
- Call the Member/Customer Service phone number for your health plan.
- State clearly that you want to file a formal complaint and then explain the problem.
- If your problem is urgent, be sure to tell your health plan. Or call one of the state help centers listed below right away.
- You can also file your complaint by letter or e-mail. Sometimes you can file a complaint through your health plan's website.
- You can ask your doctor, or a doctor outside of your health plan, to help you by writing a letter explaining why you need the service.
- You must file your complaint within 6 months after the incident or action that is the cause of your problem.
- After you file your complaint, your health plan must give you a decision within 30 days, or 3 days if your health problem is urgent.
File an external appeal
You have the right to file an appeal if your health plan denies or delays a service. Usually you have to file a complaint with your health plan first (unless your problem is urgent). An external appeal is also sometimes called an Independent Medical Review (IMR).
You can start by calling one of the state help centers listed below.
Call a state help center if:
- Your problem is urgent.
- You filed a complaint with your plan and you disagree with your plan's decision. (Your plan's response letter will also tell you where you can go for an external appeal.)
- Your plan denies an experimental or investigational treatment for a serious condition.
- Your plan cancels your coverage.
- You have questions or need complaint or IMR (appeal) forms.
Contact a state help center for an appeal
Most people can file an appeal with one of the two state help centers listed below. If they can't help with your appeal, the state help centers will refer you to the right place.
California Consumer Assistance Program (for HMOs, EPOs, some PPOs, including Anthem Blue Cross or Blue Shield)
California Department of Managed Health Care
CDI Consumer Hotline (for some PPOs and other types of health insurance)
California Department of Insurance (CDI)