If you have a problem getting the health care services you need, talk to your doctor and health plan.
If you have original (fee-for-service) Medi-Cal, you can contact your local county office if you have a problem and want to request a Medi-Cal Fair Hearing. To learn more, see the Medi-Cal Fair Hearings section below.
Medi-Cal Managed Care complaints
All Medi-Cal health plans have a customer/member service office you can call for help. Look on your membership card for the telephone number for your plan. Your health plan member services can often help with a problem before you need to file a formal complaint.
- You have the right to file a formal complaint with your health plan.
- Call your plan and file a complaint over the phone or in writing. A complaint is also called a grievance. Your plan must give you a decision within 30 days, or in 3 days if your problem is urgent.
- If you are not satisfied with your plan’s decision, or the plan does not meet the deadline for giving you a decision, file a complaint with the state. You have 2 ways to do this:
- Ask for a Medi-Cal Fair Hearing. This is a review of your problem by the state. To learn more, see the next section below.
- File a complaint or ask for an Independent Medical Review through the Department of Managed Health Care (DMHC) Help Center. Call 1-888-466-2219 or go to www.healthhelp.ca.gov.
Please note: If you file a complaint with the DMHC Help Center and are not satisfied with the results, you can still ask for a Medi-Cal Fair Hearing. However, if you ask for the Medi-Cal Fair Hearing first, you cannot file a complaint with the DMHC Help Center.
Medi-Cal Fair Hearings
This is sometimes called a State Fair Hearing. You can apply for a fair hearing whether you have original (fee-for-service) Medi-Cal or are in a Medi-Cal Managed Care health plan.
- You also can ask for a hearing if you applied to Medi-Cal and were denied.
- If Medi-Cal is going to stop a service you are getting, Medi-Cal will continue to pay for the service while a fair hearing is being conducted. To keep your services, you must ask for the hearing before the date the services will be stopped.
- You can request a hearing by contacting the California Department of Social Services at 1-800-952-5253. Or call your county's Medi-Cal office.
- The Department of Social Services oversees hearings. The hearing is a review by an administrative law judge.
- If you receive a Notice of Action in the mail that has a Medi-Cal decision that you disagree with, you can ask for a hearing. Follow the instructions on the back of the notice.
- If you disagree with an eligibility decision made by Covered California about Medi-Cal, you can request a State Fair Hearing using Covered California's appeal request form. Contact Covered California at 1-800-300-1506 for more information.
- There is a time limit. You must ask for the hearing within 90 days of the action by the county, state agency, or Covered California. (This is often the mailing date of the Notice of Action).
- To learn more, visit the Department of Health Care Services website and the Department of Social Services website.
More about the review of Medi-Cal complaints
This chart outlines State Fair Hearings reported by the Department of Health Care Services for OPA's annual Complaint Data Report. Also find information about health plan complaints reviewed by the Department of Managed Health Care.
|2015 State Fair Hearings on Medi-Cal |
(conducted by the Department of Social Services)
|Most Common Reasons for Hearings
- Pharmacy benefits (40%)
- Quality of care (25%)
- Dis-enrollment and enrollment issues (22%)
- Billing and reimbursement issues (4%)
- Medical necessity denial (4%)
- Rehabilitative and habiliatative care issues (2%)
- Claim denial (1%)
- Access to care (1%)
- Other issues (1%)
- Scope of benefits (82%) - This category includes access to care, quality of care, and service denial issues
- Medical necessity denial (12%)
- Claim denial (6%)
- Other issues (less than 1%)
Of the 13 mental health complaints, the most common reason was denied services.
|Most Common Results from Hearings
- Complaint withdrawn (48%)
- Health plan position upheld (23%)
- No action requested or required (18%)
- Health plan in compliance (5%)
- Health plan position overturned (3%)
- Referred to outside agency or department (2%)
- Compromise settlement or resolution (1%)
|Number of Days the Hearing Process Usually Takes
||Between 0-200 days|
- There is a faster review process for an urgent health issue.
View complaint statistics reported by DHCS for prior years
Cal MediConnect is a program in eight counties for people with both Medicare and Medi-Cal. If you have a problem with your services or a Cal MediConnect plan, you can get help from the Cal MediConnect Ombudsman program.
- To reach Cal MediConnect Ombudsman services, call 855-501-3077.
- Visit the Calduals.org website for more information and office locations.
More information and help with Medi-Cal
State Fair Hearings on Medi-Cal and other programs (California Department of Social Services)
Department of Managed Health Care complaint application form
OPA Complaint Data Reports
List of consumer assistance helplines
Tips on how to file a complaint