Coverage Resources Available: Help with Complaints & Concerns

November 4, 2014

Today on Ask ITUP we have a question on where to go for concerns, complaints, and questions.

How can consumers make complaints about coverage?

It depends on the type of concern. For example, insurance companies have formal grievance processes for claim and prior authorization denials. Some folks have complaints about narrow networks they are taking up with both the health plan and the Department of Managed Health Care (for HMOs) and Department of Insurance (for PPOs). Covered California has an appeals process for eligibility and subsidy determinations, as well as disenrollment and individual mandate exemptions determinations.

For Medi-Cal, go to the county Department of Public Social Services (or Human Services, in some counties) for eligibility issues. Information on care/claims denials and access to care issues should be sent to the managed care plans, the Office of the Patient Advocate, or the Medi-Cal Managed Care Ombudsman, or to the county offices if you receive fee-for-service Medi-Cal. You also have a right to request a fair hearing within 90 days of a denial or service

To initiate a grievance with a health plan, simply call the member services number on your insurance card and state that you would like to file a compliant. Plans must review complaints in a timely manner. If you go through the grievance process with a plan (private or Medi-Cal) and you do not agree with its decision, then you can ask the State to review the complaint.

Here are some resources for where to take concerns, ask for help, and get more information. The Office of the Patient Advocate is a great place to start.

Screenshot 2014-11-04 12.06.05


Health plan help:
Office of the Patient Advocate California
Consumer Assistance Program

Department of Managed Health Care

Department of Insurance

Medi-Cal questions:
Managed Care Ombudsman

County Social/Human Services Offices

Health Care Options

Covered California appeals:

Access & eligibility issues:
Health Consumer Alliance

Medicare questions:
Health Insurance Counseling & Advocacy Program