Part 2: Insurance Company Complaints

Welcome to part 2 of of our 3-part series on filing insurance company complaints.

Part 1: Overview
Part 2: California Health Plan Complaint Process (below)
Part 3: Filing a Complaint with the California Department of Insurance

CALIFORNIA HEALTH PLAN COMPLAINT PROCESS

Who Regulates What Type of Health Plan?
The majority of California’s health plans are regulated by either the California Department of Insurance (CDI) or the California Department of Managed Health Care (DMHC). The CDI regulates point-of-service health plans and certain Preferred Provider Organization (PPO) health plans underwritten by health insurance companies authorized by the CDI.

The CDI does not regulate Health Maintenance Organizations (HMOs) or certain PPOs, which fall under the Knox-Keene Act (i.e. Blue Cross of California or Blue Shield of California).

For a list of health insurance companies regulated by the Department of Insurance, visit their website at www.insurance.ca.gov. For a list of the HMOs and other healthcare service plans regulated by the Department of Managed Health Care, please visit the DMHC website at www.dmhc.ca.gov. Directions for filing a complaint with both agencies are provided below.

Filing a Complaint With the Department of Managed Health Care (DMHC)
There are several things you can do if you have a problem with your health plan. First, contact your health plan to file a complaint. (A complaint is also called a grievance or an appeal.) You can file a complaint with your health plan over the phone or in writing. You may also be able to file a complaint on your health plan's website.

If your health problem is urgent, or if you already filed a complaint and are not satisfied with your health plan's decision, contact the HMO Help Center at the DMHC. An urgent problem is a serious threat to your health. You can also file a complaint with the HMO Help Center if your HMO does not make a decision within 30 days.

The HMO Help Center can help you with your complaint. They will also provide you with an Independent Medical Review (IMR), if you qualify.

Step 1: Contact Your Health Plan
If you have a problem with your health plan, you have the right to file a complaint with your health plan.

How to file a complaint with your health plan:

• You can file a complaint with your health plan by phone or by mail. You may also be able to file a complaint on your plan's website.
• If your problem is urgent, meaning there is a serious threat to your health, your health plan must give you a decision within 3 days.
• If your problem is not urgent, your health plan must give you a decision within 30 days.

You can file a complaint with the HMO Help Center at the DMHC if you are not satisfied with your health plan's decision or if you have not received the plan's decision within 30 days or within 3 days if the problem is urgent.

Step 2: Contact the DMHC HMO Help Center
The HMO Help Center is a part of the DMHC. The DMHC oversees HMOs and some other health plans in California. The HMO Help Center can help you with your complaint. The DMHC can also give you an Independent Medical Review if you qualify.

 

File a complaint with the HMO Help Center if:

• Your problem is urgent and waiting to finish your health plan's complaint (grievance) process will be a serious risk to your health.
• You have not received a decision from your health plan within 30 days, or within 3 days if your problem is urgent.
• You are not satisfied with your health plan's decision.

How to file a complaint with the HMO Help Center:

• To file an urgent complaint, call the HMO Help Center.
• To file a complaint that is not urgent, fill out and mail a complaint form provided by the DMHC.

HMO Help Center
(888) HMO-2219 ((888) 466-2219)
(877) 688-9891

There is no charge for your call.The HMO Help Center is open 24 hours a day, 7 days a week. The HMO Help Center can provide help in many languages.

Step 3: Ask for an Independent Medical Review (IMR)
If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can ask the HMO Help Center for an Independent Medical Review (IMR). An IMR is a review of your case by doctors who are not part of your health plan. If the IMR is decided in your favor, your plan must give you the service or treatment you requested. You pay no costs for an IMR.

You can apply for an IMR if your health plan:

• Denies, changes, or delays a service or treatment that you think you need.
• Will not cover an experimental or investigational treatment for a serious medical condition.
• Will not pay for emergency or urgent medical services that you have already received.

Before you apply:

In most cases, you must complete your health plan's complaint process before you apply for an IMR. Your plan must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health.

If your plan denied your treatment because it was experimental/ investigational, you do not have to take part in your plan's complaint process before you apply for an IMR.

You must apply for an IMR within 6 months after your health plan sends you a written decision about your complaint.

How to apply:

• Fill out the IMR Application Form. This form is obtained from the DMHC.
• Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The HMO Help Center cannot return any documents.
• If you have questions about filling out your application form, call the HMO Help Center at 1-888-HMO-2219 or (TDD) 1-877-688-9891. There is no charge for this call.
• Mail or fax your form and any attachments to:

HMO Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Fax: (916) 229-0465

The HMO Help Center will review your application and send you a letter within 5 days. This letter will tell you if you qualify for an IMR. The IMR decision is then made within 30 days, or within 3 to 7 days if your problem is urgent.

Go to Part 3: Filing a Complaint with the California Department of Insurance.