How to File a Complaint, Grievance, Appeal, or Request for Independent Medical Review

If you do not agree with a coverage decision by your insurance plan, the first step is to file a grievance/appeal with your health plan by phone, mail, fax. You may also be able to file on your plan’s website. If you don’t get traction with your appeal, review your next steps in the letter the insurance company sent, which is to file your next appeal/complaint with California Department of Managed Health Care (regulates most HMO plans), or California Department of Insurance (regulates most PPO plans).

Health plans are required by law to have a grievance process in place to resolve member complaints within 30 days. In most circumstances, you are required to file a grievance regarding each issue/request with your health plan and participate in the process for 30 days before submitting a complaint to the Department. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational in either instance, you may seek DMHC’s help immediately.

California Department of Managed Health Care (DMHC)
The DMHC regulates most HMO plans

  • Phone: 888-466-2219
  • Web: http://www.dmhc.ca.gov/
  • Click “File a Complaint” or call 1-888-466-2219
  • Call if you have an immediate need for health services and a delay could seriously jeopardize your health.
  • Email inquiries: please use the DMHC website Contact Form.

California Department of Insurance (DOI)
The DOI regulates most PPO plans

Covered California

  • If you do not agree with an enrollment decision by Covered CA, call them at 800-300-1506 and ask for an appeal form. It is called Request for a State Fair Hearing to Appeal a Covered CA Eligibility Determination.
  • If you do not agree with a coverage decision made by your insurance plan, do not call Covered CA, but instead file a grievance/appeal with your health plan by phone or by mail. You may also be able to file on your plan’s website.

Medi-Cal

Health plans are required by law to have a grievance process in place to resolve member complaints within 30 days. In most circumstances, you are required to file a grievance regarding each issue/request with your health plan and participate in the process for 30 days before submitting a complaint to the Department. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational in either instance, you may seek DMHC’s help immediately.

Published by

Michael Grodsky

Michael Grodsky, AIF, is founder of Artist Insurance Services, providing unbiased education and access to health insurance for Californians. He is a board member for Side Street Projects, a nonprofit artist-run organization, and is an insurance and financial planning specialist for GYST, an artist-run company providing information and technology solutions for artists. Michael’s Health Insurance 101 workshops have been hosted by non-profit organizations throughout Los Angeles County. He leads the ‘Health Insurance 101’ monthly informational workshop at the Cancer Support Community-Benjamin Center.