An appeal is different from a complaint.
An appeal is a request for us to review and change a decision we made about your services. If we sent you a Notice of Action (NOA) letter telling you that we are denying, delaying, changing or ending a service, and you do not agree with our decision, you can ask us for an appeal. Your authorized representative or 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 while you wait for your appeal to be decided. This is called Aid Paid Pending. To get 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 will stop, whichever is later. When you request an appeal under these circumstances, the services will continue.
You can file an appeal by phone, in writing or online:
- Online:
You can submit an online Appeal
- 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
Your doctor’s office will have appeal forms available.
If you need help asking for an appeal or with Aid Paid Pending, we can help you.
We can give you no-cost 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 telling you 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 give you our appeal decision within 30 days, you can request a State Hearing from the California Department of Social Services (CDSS) and an Independent Medical Review (IMR) with DMHC. But if you ask for a State Hearing first, and the hearing has already happened, you cannot ask for an IMR with DMHC. 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 decide within 72 hours of receiving your appeal.