About the Complaint Data Reports
The Office of the Patient Advocate (OPA) was originally tasked with producing an annual report on health care complaint data and other consumer assistance information though legislation enacted in 2011 and further detailed in 2014. The reporting requirement transferred in 2021 to the Center for Data Insights and Innovation (CDII) at the California Health and Human Services Agency. View the related reporting requirements outlined in California Health and Safety Code Section 130204.
Data Collection and Analysis
For the annual reports, CDII (previously 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.
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
Complaint Data Methodology and Definitions
CDII (previously OPA) is dedicated to standardizing complaint reporting. Many of the terms used in the Complaint Data Reports are based on complaint categories and elements defined by the National Association of Insurance Commissioners. OPA worked with the state reporting entities to add to and adjust the standard elements to meet their reporting needs.
DMHC, DHCS, CDI, and Covered California report annual complaint data to CDII (previously OPA) about their consumer health care complaints that were closed between January 1 – December 31 of each Measurement Year.
The reporting entities and CDII continue to collaborate to enhance the annual Complaint Data Report. Significant changes to data collection or reporting methodologies are noted in the each annual report’s detailed methodology.
The annual reports rely on two primary data distinctions for reporting on consumer assistance cases.
- Complaint: A written or oral complaint, grievance, appeal, independent medical review, hearing, and similar process to resolve a consumer problem or dispute.
- Inquiry: A request for assistance made by a consumer to a consumer assistance service center that does not initiate a complaint with the associated reporting entity. Inquiries include requests that the service centers address by providing information to the consumer or by making a referral to another entity.
View the most recent Report Glossary for additional complaint data and consumer assistance terms.
Other Complaint Data Resources
The following state websites have reports and other information about health care coverage complaints in California. The National Association of Insurance Commissioners online resource has national statistics about insurance complaints.
Department of Managed Health Care
- DMHC Health Plan Dashboard
- Annual Reports on Complaints and Independent Medical Reviews
- Independent Medical Review Database
Department of Insurance
Department of Health Care Services
Department of Social Services
National Association of Insurance Commissioners