Grievances and Appeals Resources

The Center for Medicaid & Medicare Services (CMS) has a program called The Office of the Medicare Ombudsman. This office helps Medicare beneficiaries with complaints, grievances, and information requests. For more information, visit  the Medicare website. (By clicking on this link, you are leaving our website.)

California Department of Managed Health Care

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against your health plan, you should contact us and use our grievance process before contacting the DMHC.

Using this grievance process does not prohibit any potential legal rights or solutions for you. If you need help with a grievance for an emergency, a grievance that has not been resolved by us to your satisfaction, or a grievance that has remained unresolved for more than 30 days, you may call the DMHC for help. You may also be eligible for an Independent Medical Review (IMR).

If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by us and for the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical service.

DMHC also has a toll-free telephone number, 1-888-HMO-2219, and a TDD line, 1-877-688-9891, for the hearing and speech impaired. Visit  the DMHC website to get complaint forms, IMR application forms, and instructions(when you click on his link, you will be leaving this website).

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Last updated 12042013