California DMHC — Health Plan Complaints & Medical Review

The mission of the Department of Managed Health Care (DMHC) is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system.

The DMHC Help Center educates health plan members about their health care rights, resolves member complaints against health plans, helps members understand their coverage and assists members in getting timely access to appropriate health care services.

The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans.

You can also file a Consumer Complaint when you have other issues with your Health Plan.

If your Health Plan denies, changes or delays your request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment for a serious medical condition, you can apply for an Independent Medical Review (IMR).

How to File a Grievance/Complaint with Your Health Plan

DMHC Protected Messages

Make sure your health plan is licensed by the DMHC. If your plan is not licensed by the DMHC, we will close your case and direct you to the appropriate department or agency for assistance.

Currently, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) regulate Covered California health plans. At this time, the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and we find that your health plan is under the jurisdiction of CDI, we will forward your complaint to CDI.

These issues can consist of billing problems, cancellation of coverage, claim and copay disputes, delays in getting an appointment, referral or authorization, access to translation services, finding an in-network doctor, hospital, or specialist, complaints about a doctor or plan and continuity of care.

Health plans are required by law to have a grievance process in place to resolve enrollee 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 DMHC. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational. In either of these instances, you may seek immediate assistance from the DMHC.

You can file a complaint with the Help Center if you are not satisfied with your health plan's decision or if you have not received your health plan's decision within 30 days.

Most times, the DMHC will review and make a decision within 30 days from receipt of your complaint. However, due to the complexity of your complaint, the Consumer Complaint process could take longer than 30 days.

If you plan to attach supporting documents such as copies of denials, letters or bills, save the documents on your computer before you complete the form.

The maximum file size for supporting documents is 25MB (approximately 100 pages or more).

The system will accept most file formats such as Word, Excel, PDF, or JPG. It will not accept sound or video files or emails. If you wish to submit a copy of an email message, copy and paste the email message into a Word file.

You should print a copy of your form before submitting. Once you submit your form, you will not be able to print a copy. You may need to adjust your margin settings before printing. Preview your form before printing.

Your browser needs to have Javascript enabled. The form may not function properly if Javascript is not enabled.

The DMHC will only send you a request if more information is required. If you send the DMHC more information the DMHC did not request, we will not accept the additional information once a complete IMR/Complaint has been submitted. This means that any materials you send to the DMHC after your IMR/Complaint is submitted will not be reviewed.

You have the option to submit your IMR/Complaint form in many languages by mail or by fax. Be sure to complete all fields, include any copies of supporting documents and sign the form.

The DMHC Help Center provides direct assistance in all languages to health plan members.

However, the DMHC must have on file a completed and signed DMHC Authorized Assistant Form. The DMHC cannot speak to anyone about your Independent Medical Review or Consumer Complaint unless we have your authorization to do so. Completion and submission of the DMHC Authorized Assistant Form tells the DMHC that it has your permission to speak with the person you have designated as your authorized assistant or representative.

A completed and signed DMHC Legal Representative for Deceased Patient Form; A copy of the deceased's death certificate; and Documentation naming you the legal representative of the deceased (i.e., copy of a probate court order naming you as the executor/executrix of the estate, or documentation of guardian status if the deceased was a minor).

The Department’s downtown Sacramento office is currently not accessible to the public. If you have a need for in-person services, please email PublicAccessRequest@dmhc.ca.gov to request an appointment.

The DMHC will not provide you with IMR/Complaint status updates. Once the DMHC has completed its review of your IMR/Complaint, you will receive a closing letter from the DMHC.

Please note, the DMHC does not accept appeals of the determination. If you have a new issue or your medical condition changes, you will be required to submit a new IMR/Complaint to the DMHC.

Your health plan membership card has a member services phone number listed on the card. You can call that number if you want to file a complaint (grievance or appeal). Additionally, you can find your health plan's member services contact information by selecting the "View All Health Plans" link below.

A request will qualify for an IMR if your health plan: Denies, modifies, or delays a service or treatment because the health plan determines it is not medically necessary. Will not cover an experimental or investigational treatment. Will not pay for emergency or urgent medical services that you have already received.

Do you have Medi-Cal?  Yes  No If yes, have you filed a Request for a State Fair Hearing?

The DMHC will review your Independent Medical Review Application/Complaint Form to decide if the service you want is a covered benefit. If the service is not covered, we will inform you that you do not qualify for an IMR and your complaint will be reviewed as a Consumer Complaint.

The Help Center will send you a letter informing you that your problem does not qualify for an IMR. If this happens, the Help Center will review your case through its Consumer Complaint process and send you a written decision within 30 days. You do not need to send in another form.

If your plan denied your treatment because it was experimental/investigational, you do not have to take part in your plan’s complaint or grievance process before you file an IMR application.

Please note: the following are general timeframes and are not guaranteed. Many factors may require additional time to process your IMR/complaint to ensure a thorough review. Complaints are generally determined within 30 days from the date of receipt. IMR cases are generally determined within 45 days from the date the case qualifies for an IMR.

If your health problem is not urgent, an IMR is usually decided within 45 days after we receive the supporting documentation from you, the doctor, and the health plan. An IMR can take longer if we do not receive all of the medical records we need from you or your treating doctor. If you are seeing a doctor who is not in your health plan's network, it is important that you obtain and send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.

If your health problem is urgent, an IMR is usually decided within 7 days after we receive the supporting documentation from you, the doctor, and the health plan. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.

If you have medical records from out of network providers, please include them with your IMR Application/Complaint Form. Your plan will provide medical records from network providers.

I allow my providers, past and present, and my plan to release my medical records and information to review this issue. These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and other records related to my case. These records may also include non-medical records and any other information related to my case. I allow the Department to review these records and information and send them to my plan. My permission will end one year from the date below, except as allowed by law. For example, the law allows the Department to continue to use my information internally. I can end my permission sooner if I wish.

If the IMR decision is in your favor, the health plan must authorize the service(s) or treatment(s) within five business days.

FREE: The IMR/Complaint process is free.

If the complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.

If you noted on the DMHC IMR/Complaint form that you would like communication/correspondence sent to your email, the DMHC will provide you with correspondence related to your complaint via a protected email. A protected email is an encrypted message that keeps information about you private.

1. Click the "Read the message" button in your email. 2. You will be redirected to a secure web page, click the "Sign in with a One-time passcode" button. 3. Check your email for the one-time passcode. 4. Return to your browser and enter the code in the "One-time passcode" field, then click "Continue" to read your message.

Phone: 1-888-466-2219 (TDD: 1-877-688-9891)

Phone: 1-888-466-2219 (TDD: 1-877-688-9891)

Fax: 916-255-5241

If you have questions about the complaint process or need more information, please email us at Helpline@dmhc.ca.gov. If you already have a case open with the DMHC, be sure to include your case number with any questions you submit.

Mailing Address Department of Managed Health Care 980 9th Street, Suite 500 Sacramento, CA 95814-2725

If you have a need for in-person services, please email PublicAccessRequest@dmhc.ca.gov to request an appointment.

If you have technical difficulties completing this form, please contact wpso@dmhc.ca.gov for assistance.

The DMHC contracts with the Health Consumer Alliance, a group of local, community-based organizations that will provide you with assistance filing a grievance with your health plan. If you need one-on-one assistance, please contact the Health Consumer Alliance’s Consumer Assistance Program at 1-888-804-3536.

IMR APPLICATION/COMPLAINT FORM - ENGLISH

AUTHORIZED ASSISTANT FORM

Independent Medical Review/Complaint Forms

View All Health Plans

The organization shall complete its review and make its determination in writing, and in layperson’s terms to the maximum extent practicable, within 30 days of the receipt of the application for review and supporting documentation, or within less time as prescribed by the director.

If the disputed health care service has not been provided and the enrollee’s provider or the department certifies in writing that an imminent and serious threat to the health of the enrollee may exist, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the health of the enrollee, the analyses and determinations of the reviewers shall be expedited and rendered within three days of the receipt of the information.

Subject to the approval of the department, the deadlines for analyses and determinations involving both regular and expedited reviews may be extended by the director for up to three days in extraordinary circumstances or for good cause.

(j) An enrollee may apply to the department for an independent medical review when all of the following conditions are met: (1) (A) The enrollee’s provider has recommended a health care service as medically necessary, or (B) The enrollee has received urgent care or emergency services that a provider determined was medically necessary, or (C) The enrollee, in the absence of a provider recommendation under subparagraph (A) or the receipt of urgent care or emergency services by a provider under subparagraph (B), has been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which the enrollee seeks independent review. The plan shall expedite access to an in-plan provider upon request of an enrollee. The in-plan provider need not recommend the disputed health care service as a condition for the enrollee to be eligible for an independent review. For purposes of this article, the enrollee’s provider may be an out-of-plan provider. However, the plan shall have no liability for payment of services provided by an out-of-plan provider, except as provided pursuant to subdivision (c) of Section 1374.34. (2) The disputed health care service has been denied, modified, or delayed by the plan, or by one of its contracting providers, based in whole or in part on a decision that the health care service is not medically necessary. (3) The enrollee has filed a grievance with the plan or its contracting provider pursuant to Section 1368, and the disputed decision is upheld or the grievance remains unresolved after 30 days. The enrollee shall not be required to participate in the plan’s grievance process for more than 30 days. In the case of a grievance that requires expedited review pursuant to Section 1368.01, the enrollee shall not be required to participate in the plan’s grievance process for more than three days. (k) An enrollee may apply to the department for an independent medical review of a decision to deny, modify, or delay health care services, based in whole or in part on a finding that the disputed health care services are not medically necessary, within six months of any of the qualifying periods or events under subdivision (j). The director may extend the application deadline beyond six months if the circumstances of a case warrant the extension.

If the enrollee’s physician determines that the proposed therapy would be significantly less effective if not promptly initiated, the analyses and recommendations of the experts on the panel shall be rendered within seven days of the request for expedited review. At the request of the expert, the deadline shall be extended by up to three days for a delay in providing the documents required. The timeframes specified in this paragraph shall be in addition to any otherwise applicable timeframes contained in subdivision (c) of Section 1374.33.

(a) Every health care service plan shall provide an external, independent review process to examine the plan’s coverage decisions regarding experimental or investigational therapies for individual enrollees who meet all of the following criteria: (1) (A) The enrollee has a life-threatening or seriously debilitating condition. (B) For purposes of this section, “life-threatening” means either or both of the following: (i) Diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted. (ii) Diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival. (C) For purposes of this section, “seriously debilitating” means diseases or conditions that cause major irreversible morbidity. (2) The enrollee’s physician certifies that the enrollee has a condition, as defined in paragraph (1), for which standard therapies have not been effective in improving the condition of the enrollee, for which standard therapies would not be medically appropriate for the enrollee, or for which there is no more beneficial standard therapy covered by the plan than the therapy proposed pursuant to paragraph (3). (3) Either (A) the enrollee’s physician, who is under contract with or employed by the plan, has recommended a drug, device, procedure, or other therapy that the physician certifies in writing is likely to be more beneficial to the enrollee than any available standard therapies, or (B) the enrollee, or the enrollee’s physician who is a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the enrollee’s condition, has requested a therapy that, based on two documents from the medical and scientific evidence, as defined in subdivision (d), is likely to be more beneficial for the enrollee than any available standard therapy. The physician certification pursuant to this subdivision shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation. Nothing in this subdivision shall be construed to require the plan to pay for the services of a nonparticipating physician provided pursuant to this subdivision, that are not otherwise covered pursuant to the plan contact. (4) The enrollee has been denied coverage by the plan for a drug, device, procedure, or other therapy recommended or requested pursuant to paragraph (3). (5) The specific drug, device, procedure, or other therapy recommended pursuant to paragraph (3) would be a covered service, except for the plan’s determination that the therapy is experimental or investigational.

Medi-Cal fee-for-service members (Medi-Cal members who are not in a managed care plan). Members of self-insured and self-funded plans. An enrollee disputing a workers' compensation claim.

(f) Medi-Cal beneficiaries enrolled in a health care service plan shall not be excluded from participation. Medicare beneficiaries enrolled in a health care service plan shall not be excluded unless expressly preempted by federal law. Reviews of cases for Medi-Cal enrollees shall be conducted in accordance with statutes and regulations for the Medi-Cal program.

[COHS plans that do not have a Knox-Keene license may remove this section.]

You are entitled to both a State Hearing and an IMR. But if you ask for a State Hearing first and the hearing to address your specific issues has already happened, you cannot ask for an IMR with DMHC on the same issues. In this case, the State Hearing has the final say. But you may still file a complaint with DMHC if the issues do not qualify for IMR, even if the State Hearing has already happened.

You must ask for an IMR within six months from the date on the notice telling you of the appeal decision, but you only have 120 days to request a State Hearing. So, if you want an IMR and a State hearing, file your complaint as soon as you can.

You must file an appeal with your plan within 60 days of the date on the Notice of Action. After you file your appeal, the plan will send you a decision within 30 days.

You must ask for a State Fair Hearing within 120 days of the date of the plan’s written appeal decision.

If you are in Fee-for-Service Medi-Cal and you get a Notice of Action letter telling you that a health service or benefit has been denied, you have the right to ask for a State Fair Hearing right away. You must ask for a State Fair Hearing within 90 days of the date on the Notice of Action.

With the resumption of redeterminations, DHCS received approval from CMS to temporarily extend the timeframe permitted for Medi-Cal members to request a redetermination eligibility-related fair hearing to 120 days from the date the notice of action is mailed. The temporary extension for Medi-Cal members to request a fair hearing is effective April 1, 2023 and remains effective until further notice. This extended time frame only includes redetermination eligibility-related fair hearing requests, including terminations of Medi-Cal eligibility, reductions in benefits (from full Medi-Cal benefits to limited Medi-Cal benefits), and increases in beneficiary liability or share-of-cost.

The extended time frame does not apply to new Medi-Cal applications, medical exemption requests or hearing requests related to a request for a particular treatment or service under the Medi-Cal program.

If you do not agree with a decision related to your Medi-Cal Rx pharmacy benefit, you may ask for a State Hearing. You cannot ask DMHC for an IMR for Medi-Cal Rx pharmacy benefit decisions.

Complaints and appeals related to pharmacy benefits not subject to Medi-Cal Rx may be eligible for an Independent Medical Review (IMR) with DMHC.

If we gave you Aid Paid Pending during your appeal and you want it to continue until there is a decision on your State Hearing, you must ask for a State Hearing within 10 days of our NAR letter or before the date we said your services will stop, whichever is later.

Sometimes you can ask for a State Hearing without completing our appeal process. For example, if [MCP] did not notify you correctly or on time about your services, you can request a State Hearing without having to complete our appeal process. This is called Deemed Exhaustion.

If you or your doctor wants us to make a fast decision because the time it takes to decide your appeal would put your life, health, or ability to function in danger, you can ask for an expedited (fast) review. To ask for an expedited review, call [Member Services telephone number] (TTY [Member Services TTY number] or 711). We will decide within 72 hours of receiving your appeal.

If you want CDSS to make a fast decision because the time it takes to have a State Hearing would put your life, health, or ability to function fully in danger, you, your authorized representative, or your provider can contact CDSS and ask for an expedited (fast) State Hearing. CDSS must make a decision no later than three business days after it gets your complete case file from [MCP].

You may complete the "Request for State Hearing" on the back of the Notice of Action or put your request on a separate piece of paper. Please provide all requested information such as your full name, address, telephone number, the name of the county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. If you have trouble understanding English, be sure to tell us your language (and dialect) so we can arrange for you to have language assistance at the hearing. If you have chosen an authorized representative, be sure to tell us his/her name and address. If you wish, you may attach a letter in which you explain why you believe the county action is not correct. It is always a good idea to keep a copy of your hearing request.

Call the State Hearings Division toll free (800) 743-8525

1-800-743-8525, (TTY 1-800-952-8349)

Hearing Requests

My Rights

[MCP] Combined Evidence of Coverage (EOC)