If you have a complaint against your health care service provider in California, the first step is to contact your health plan directly. You can find their contact information on their website or by calling their toll-free number (1-877-658-030). It is important to use your health plan's complaint process before contacting the California Department of Managed Health Care (DMHC). Doing so does not prevent you from exercising any legal rights or remedies that may be available to you. If you need help with an emergency complaint, one that your health plan has not resolved satisfactorily, or one that has remained unresolved for more than 30 days, you can call the DMHC for assistance.
You may also be eligible for an independent medical review (IMR). The IMR process will include an impartial review of medical decisions made by a health plan related to the medical need for a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and disputes over payment of emergency or emergency medical services. The DMHC also has a toll-free telephone number (1-888-466-221) and a TDD line (1-877-688-989) for people with hearing and speech impairments. Their website, www.dmhc.ca.gov, has complaint forms, IMR application forms, and online instructions. The preferred method for submitting a concern is through their online submission form, as it allows you to receive and review your concerns in a more direct and timely manner. If your health plan denies your request for medical services or treatment, you can file a grievance (formal complaint) with your plan.
Most California health plans are regulated by the California Department of Insurance (CDI) or the California Department of Managed Health Care (DMHC).If your health problem is urgent or if you have already filed a complaint and are not satisfied with your health plan's decision, contact the DMHC HMO Help Center. You can file a complaint with the Department of Insurance by completing a request for assistance for health care providers (HPRFA) for each claim submitted to the insurer. If you have determined that the plan is regulated by the CDI and you have submitted a dispute to the insurer for review under the Dispute Resolution Mechanism process, and you do not agree with the decision or want the CDI to review an issue, you can file a complaint by completing a request for assistance for a health care provider (HPRFA).If you have a problem with your health plan, you have the right to file a complaint with your health plan. For more information on the complaint process, please refer to our FAQs.