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​About the Complaint Data Reports

The Office of the Patient Advocate was tasked with producing an annual report on health care complaint data and other consumer assistance information. The reporting requirement is transferring to the Center for Data Insights and Innovation at the California Health and Human Services Agency. 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

Complaint Data Methodology and Definitions

OPA is dedicated to standardizing complaint reporting. Many of the terms used in the OPA Complaint Data Reports are based on complaint categories and elements defined by the National Association of Insurance Commissioners. OPA has worked with the state reporting entities to add to and adjust the standard elements to meet their reporting needs.

Methodology

DMHC, DHCS, CDI, and Covered California report annual complaint data to OPA about their consumer health care complaints that were closed between January 1 – December 31 of each Measurement Year.

The reporting entities and OPA continue to collaborate to enhance the Complaint Data Report. Significant changes to data collection or reporting methodologies are noted in the each annual report’s detailed methodology.​

  • ​​View the detailed methodology from the most recent Complaint Data Report.
  • Prior years’ methodologies can be found in the each annual report’s Background and Methodology section.

Definitions

OPA relied 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

Department of Insurance

Department of Health Care Services

Department of Social Services

National Association of Insurance Commissioners