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Last updated January 1, 2014

If you have had medical services or prescription drugs denied by your HMO or other health plan, please read this to get an idea of what recourse for appealing that denial is. If you do not live in California, you can still try the same things, but do check with your own state medical association, state insurance commissioner, and/or board of consumer affairs.

As a health care consumer, there may be times when you are unhappy with your physician, hospital, or health plan and need to make a complaint. Some problems can be resolved informally simply by talking to the parties involved, but others will require that you follow an official set of "grievance procedures". The following guidelines explain what to do and who to contact for more information.

Complaints About Physicians
If you are unhappy with something your doctor has said or done, it's important that you speak to him or her about it as soon as possible, especially if it concerns your health. Often a frank conversation is enough to solve the problem.

If not, here are a couple other things you can do: If your physician is a member of the California Medical Association, you can discuss your problem with the medical society in the county where the physician practices. The society will arrange for other physicians, and possibly a mediation committee, to study the problem. Physicians who are CMA members are required to go through this dispute resolution process if a patient requests it. Click here for a list of county medical society phone numbers and websites.

If your doctor is not a CMA member, or you want to take additional action, you can contact the California Medical Board's Central Complaint Unit at 1-800-633-2322 or (916) 263-2424. The Medical Board will start an investigation, and if necessary, submit your case to the California Attorney General. The Medical Board is the organization that licenses physicians, surgeons and other health care providers. They are the only group that has the authority to take away a physician s license.

Complaints About Hospitals
If you're having a problem with your hospital, the first step is to contact the hospital's "patient complaint coordinator". People in this position are very knowledgeable about their hospital's practices and procedures and can often help you resolve problems.

If you want to take further action, you might contact a representative of your health plan. Health plans want you to be happy with the care you are getting under their coverage and are often willing, to help you solve any problems you may be experiencing.

You can also contact The Joint Commission on Accreditation of Healthcare Organization. The Joint Commission, along with the California Medical Association, conducts surveys to be sure that hospitals are providing quality care. Ask them to investigate your complaint. You can reach them through their website or call them at (630) 792-5000.

The government agency responsible for licensing and regulating hospitals is the California Department of Health Services (DHS). To file a complaint, you need to contact the district office in the area where the hospital is located.

Complaints About Health Plans
You have many rights and protections when it comes to health plans, especially if your plan is an HMO. (To learn the difference between types of plans, go to What type of health plan is best for me?). Until recently, though, there were few ways to get your problems solved without going to court.

The California Medical Association has worked to make it possible for patients to solve their problems with health service plans, including HMOs, in a faster, less complicated way. We recently sponsored a new law that lays out grievance procedures that can be used for any concern, for example a charge that your health plan refused to pay or an instance when you had to wait an unreasonably long time to see a doctor.

These instructions will take you through the process of filing a complaint and tell you what to expect along the way. You'll want to follow somewhat different guidelines if your problem is an emergency.

Step One: Write a Letter to Your Health Plan
The first step is to tell your health plan about your problem in writing. We suggest that you:

• Write your letter as soon as possible, while all the facts are still fresh in your mind.

• Explain the situation in a brief, clear way, including facts (names, dates, places, etc.) whenever possible.

• Tell your plan exactly what you want them to do to solve the problem. Include copies of any papers that relate to the problem (statements, checks, etc.)

• Try to stick to the facts and avoid exaggerating.

Here is a sample letter you may wish to use as a guide (Download text verion):

Your Name
Your Address
Your City, State, Zip Code

Date

Grievance Department
Health Plan Name
Street Address
City, State, Zip Code

Policy Number
Member/Employee Name:

Dear Sir or Madam:

The purpose of this letter is to inform you of my problem with ___________ [Explain the problem you are having].

My complaint concerns______________ [the reason for your complaint]. In order to solve my problem, I would like _____________ [the specific action you want the plan to take].

I look forward to your reply and a resolution of my complaint.

Sincerely,

Your Name

Enclosures [Include copies of all related records. Do not send originals.]

Step Two: Complete Your Plan's Complaint Process
Each plan has it's own process for dealing with complaints. Your plan may respond to your letter by asking you to fill out a form, provide additional information or speak to a plan representative. As you go through this process, keep copies of all written communications. If you speak to someone, in person or on the phone, note the date and what was said. The law requires the plan to send you a written response within 30 days of receiving your complaint.

Step Three: Contact The Appropriate Agency
If you're not happy with the way your health plan has responded to your complaint, the next step is to contact a state agency that can take further action.

In order to know which agency to contact, you will need to find out whether your plan is an HMO or a traditional insurance plan. You can ask your employer, a plan representative, or the California Department of Corporations (DOC), the agency that regulates health care service plans (their toll-free number is 1-800-400-0815). You can also look for the information in your insurance papers in a section called the "Evidence of Coverage Statement". (Complaints about Medi-Cal and Medicare are handled by other agencies.)

If you have traditional insurance, you will need to take your complaint to the California Department of Insurance and fill out a Request for Assistance form. You can reach them through their website or by calling their consumer hotline at 1-800-927-HELP.

If you have an HMO, Blue Cross, or Blue Shield, you will need to contact the Department of Corporations (DOC) at 1-800-400-0815. (If you are hearing or speech impaired, call 1-800-735-2929 (TTY) or 888-877-5378 (TTY).

The DOC requires that you go through your plan's grievance process before they will help you. Plans governed by the DOC must try to make a decision on complaints within 30 days. If it's been 60 days since you filed a complaint, and your plan still hasn't resolved the problem, or if you don't like the plan's response, the DOC will help you.

When you contact the DOC, they will send you a complaint form to fill out. Then they will study your case and possibly request more information or hold an informal meeting with the parties involved. In most cases, all parties will receive a letter explaining the DOC's decision within 60 days.

Under the law, your doctor can assist you as you go through the complaint process. You can request that your doctor attend any informal meetings requested by the DOC.

Keep in mind that if your plan requires that you resolve problems through arbitration, you still have the option of going to the DOC beforehand. You also have the right to take legal action or go to a mediator (if the plan agrees) without going through the DOC first.

In An Emergency
If you are in a situation where your health is seriously threatened and you need fast assistance in dealing with a health plan problem, you will want to inform your plan and the DOC in writing immediately. Health plans governed by the California Department of Corporations (DOC) that is, HMOs, Blue Cross, and Blue Shield are required to resolve emergency complaints within 5 days. If you don't get the results you want, contact the DOC at 1-800-400-0815.

If you have traditional insurance, call the California Department of Insurance at 1-800-927-4357 and explain your situation. If necessary, they will contact your insurance company by phone to resolve your complaint, instead of going through their usual process, which commonly takes from 30 to 90 days.

Medicare Patients
Medicare patients are entitled to special grievance and appeal rights. Your health plan is required by law to give you a complete written explanation of your rights. Medicare also maintains a web site which is very helpful. 

Where To Send Complaints

About Physicians

Medical Board of California
1426 Howe Avenue, Suite 54
Sacramento, CA 94825
1-800-633-2322

About Hospitals

California Department of Health Services (DHS)
744 P Street
Sacramento, CA 94814
(916) 445-2070

About HMOs, Blue Cross, or Blue Shield
For Kaiser and other HMO members, you must first go through your HMO's appeal process

California Department of Insurance
Division Of Health Care Service Plans
Consumer Complaints
3700 Wilshire Boulevard, Suite 600
Los Angeles, CA 90010
1-800-400-0815 

California Department of Corporations
Department of Managed Health Care Complaint Hotline
Streamlined complaint process
888-HMO-2219

About Traditional Health Insurance Companies

California Department of Insurance
Consumers Services Division
Consumer Complaints Information
300 South Spring Street, 6th Floor, South Tower
Los Angeles, CA 90013
1-800-927-4357
Within Los Angeles: (213) 897-8921

About Medi-Cal

Medi-Cal Public Inquiry & Response    1-800-952-5253
Ombudsman for Medi-Cal Managed Care    1-888-452-8609

California Department of Health Services
744 P Street
Sacramento, CA 94814
(916) 445-4171

About Medicare

Centers for Medicare & Medicaid Services
(formerly Health Care Financing Administration)
Regional Office
75 Hawthorne Street, Suite 401
San Francisco, CA 94105
1-800-638-6833

HEALTH CONSUMER ADVOCACY GROUPS

General health plan issues:

Consumers Union
1535 Mission Street
San Francisco, CA 94103
(415) 431-6747

Senior citizen health insurance issues:

Health Insurance Counseling and Advocacy Program (HICAP)
1-800-434-0222

Center for Health Care Rights (serves Los Angeles County)
520 S. Lafayette Park Place, Suite 214
Los Angeles, CA 90057
Toll-free number in L.A. County: 1-800-824-0780

Health plan disclosure to patients:

Citizens for the "Right to Know"
925 L Street, Suite 600
Sacramento, CA 95814
(916) 443-7239

The information on this page was excerpted from http://www.cmanet.org/publicdoc.cfm/14/4.

Related Information

The California Patient's Guide: Your Health Care Rights and Remedies

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