Appeals

An appeal is different from a complaint.
An appeal is a request for us to review and change a decision we made about your service(s). If we sent you a Notice of Action (NOA) letter telling you that we are denying, delaying, changing or ending a service(s), and you do not agree with our decision, you can ask us for an appeal. Your PCP or other provider can also ask us for an appeal for you with your written permission.

You must ask for an appeal within 60 days from the date on the NOA you got from us.
If we decided to reduce, suspend, or stop a service(s) you are getting now, you can continue getting that service(s) while you wait for your appeal to be decided. This is called Aid Paid Pending. To receive Aid Paid Pending, you must ask us for an appeal within 10 days from the date on the NOA or before the date we said your service(s) will stop, whichever is later. When you request an appeal under these circumstances, the service(s) will continue.
You can file an appeal by phone, in writing or online:

  • By phone:
    Call L.A. Care Member Services at 1-888-839-9909 (TTY: 711) 24 hours a day 7 days a week including holidays.
    Give your name, health plan ID number and the service you are appealing.
     
  • By mail:
    Call L.A. Care Member Services at 1-888-839-9909 (TTY: 711) and ask to have a form sent to you. When you get the form, fill it out.
    Be sure to include your name, health plan ID number and the service you are appealing.

    Mail the form to:

     L.A. Care Health Plan
     Appeal and Grievance Department
     1055 West 7th Street, 10th Floor
     Los Angeles, CA 90017

  • Online:
    You can submit an online Appeal

If you need help asking for an appeal or with Aid Paid Pending, we can help you.
We can give you free language services. Call Member Services at 1-888-839-9909 (TTY: 711).

Within 5 days of getting your appeal, L.A. Care will send you a letter letting you know we got it.
Within 30 days, we will tell you our appeal decision and send you a Notice of Appeal Resolution (NAR) letter.

If we do not provide you with our appeal decision within 30 days, you can request a State Hearing and an IMR.
But if you ask for a State Hearing first, and the hearing has already happened, you cannot ask for an IMR. In this case, the State Hearing has final say.

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 at 1-888-839-9909 (TTY: 711).

We will make a decision within 72 hours of receiving your appeal.