Online Grievance Form

Required fields are indicated with an asterisk (*)

Members Date of Birth:

Members Date of Birth

Do you have a signed denial letter? : *

Do you have a signed denial letter?

Date of Incident/Denial:

Date of Incident/Denial

Rights for Medi-Cal Members

Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-839-9909 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. 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 a health plan related to 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 services. The department 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. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

If you have any other questions or concern(s) on this matter, please call L.A. Care at 1-888-839-9909.

Medi-Cal Members Additional Rights

State Fair Hearing

You may ask for a State Hearing within 120 days of receiving the Notice of Appeal Resolution from L.A. Care. You may either present your case yourself, or ask someone to present your case, such as legal counsel, relative, friend, or any other person. For more about State Hearing requests, please call 1(800) 952-5253. For the hearing impaired TDD, please call 1(800) 952-8349. To request a State Hearing in writing please send your letter to the following address.

California Department of Social Services
State Fair Hearing Division
P. O. Box 944243, MS 19-37
Sacramento, CA 94244-2430

California Department of Health Care Services (DHCS) Office of the Ombudsman

You may also call the Ombudsman Office of the California Department of Health Care Services (DHCS) for help. The Ombudsman Office helps Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. To find out more, call toll-free 1-888-452-8609.