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How to File a Complaint
If you have a problem getting the health care services you need, you have the right to file a grievance (complaint) with your health plan. If the health plan does not resolve your complaint or takes too long to respond, you can file an external appeal with the agency that oversees your health plan. For most people, the Department of Managed Health Care oversees their plan. The Department of Insurance oversees limited-benefit health plans and some PPOs. The basic steps to filing a complaint are listed here. Click below for assistance or for information specific to your type of health coverage.
File a 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. You can also file a complaint by letter or email.
- 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 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 Complaint
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). 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 state help centers listed below. If they can’t help with your appeal, the state help centers will refer you to the right place.
Department of Managed Health Care (for help with most health plans)
Contact DMHC for help with problems with your health plan or for referrals if you don’t know where to get help.
California Department of Insurance
Contact CDI for help with many PPO plans and help with other kinds of health insurance.
Contact Covered California to appeal a Covered California decision regarding your eligibility, or to file a complaint about a problem related to Covered California.
Health Insurance Counseling and Advisory Program (for help with Medicare)
Contact HICAP for free help with questions, problems, or complaints about your Medicare coverage.
Department of Social Services (State Fair Hearings)
Request a hearing to appeal a decision regarding your eligibility for Medi-Cal or Covered California coverage.
1-800-743-8525 or 1-855-795-0634