🔖 Archived Resource (2001): This guide was published in 2001 and is not current. It is preserved here for historical and general reference by Consumer Watchdog. Laws may have changed — consult a qualified attorney for current legal advice.

Chapter VI.
Your Right to File Grievances with your Health Plan and the Department of Managed Health Care

SUMMARY OF YOUR RIGHTS

You have the right to file a grievance with your health plan for any plan that you believe has adversely affected your health care.

You have the right to have your grievance resolved by your plan within 30 days, when possible.

You have the right to submit your grievance to the Department of Managed Health Care, after participating in your plan's grievance process for 30 days.

You have the right to have DMHC resolve your grievance within 30 days.

If you are dissatisfied with any decision made by your health plan, medical group or doctor, you have the right to file a complaint, or "grievance," with your health plan and with California's regulator of managed care plans, the Department of Managed Health Care (DMHC). Both the health plan and the DMHC must follow particular standards and timelines when reviewing and resolving your grievance. When there is no other reasonable alternative, get needed treatment first, then take the necessary steps to obtain the proper resolution to the problem you are having with your health plan.

WHEN SHOULD I FILE A GRIEVANCE WITH MY PLAN?

You should file a grievance when:

your doctor, medical group or health plan tells you the treatment you need is not covered under your benefits.

you feel the treatment or medication that has been authorized for you is not the best course of treatment, after receiving a second opinion.

your health plan is denying payment for the treatment you have already received.

the treatment you think is necessary and covered has been denied because it is considered to be experimental, investigational or not medically necessary.

WHAT ARE MY RIGHTS TO FILE A GRIEVANCE AGAINST MY HEALTH PLAN?

If you are denied access to medical services or specialists, or experience any other action by your health plan that you believe negatively affects your ability to receive quality health care, you have the right to file a grievance with your plan. Under California law, health plan must have in place a grievance system under which you can submit a grievance to the plan.¹ Each plans must adequately consider each grievance and remedy the situation when needed. You must be informed by the plan when you enroll and once a year after that about how and where to file such a grievance.²

Medi-Cal and Medicare laws also require managed care plans to have a grievance process and to inform members of their rights.

Consider the situation of Harry Christie who fought a successful battle to force his HMO to pay for his daughter's cancer surgery. Harry's daughter, Carley, was stricken with a rare cancer called Wilms tumor. Harry's HMO would not approve a surgeon who had previously performed the tumor removal procedure. The Christies decided on the spot to have the care rendered and worry about payment later. His initial decision to make certain that his daughter received the care she needed without waiting for the HMO's approval was a wise strategic choice to put her health above the HMO's rules. Today, as a result, Carley is living a happy and healthy life.

Harry's strategy was to go through every step of the process and get all the allies he could to ensure HMO payment for Carley's care and a fine for their unlawful denial. Harry's calm and deliberate demeanor led to the state of California ultimately fining his HMO $500,000 for its failure to approve the proper surgeon.

According to Harry:

"I thought I had approval the night before the surgery. Then they back-peddled and said we didn't seek pre-approval. That is a falsehood. Then it took eleven months to recover payment of the medical bills. Next time I would have gone directly to the medical group. I thought I had to do all my dealings through the managed care plan. What I didn't know was that the medical group held its own set of cards. If you know in your heart of hearts what you are being told is not right, follow your instincts and do what needs to be done and fight it afterwards."

WHAT STEPS SHOULD I TAKE BEFORE I FILE A GRIEVANCE?

Before filing a grievance with your health plan, make sure you know the answers to the following questions:

Does my health plan cover the care I am seeking?

Make sure the medical care or services you are trying to get approved are covered benefits by your health plan. Check your "Evidence of Coverage" booklet, plan contract or any other pertinent plan information to determine: 1) your covered benefits, and 2) any exclusions or limitations that are specifically not covered.
Who has made the decision to deny me coverage?

When you are denied medical care or services, determine who has made the decision. If your doctor is the source of the denial, discussing it may straighten things out. You may want to request a change of doctors, or seek out a second opinion from another doctor. You must make sure you know the reasoning behind your doctor's decision to deny, so ask for an explanation in terms you can easily understand.

If the decision came from your health plan, contact the plan's customer service department. Request an explanation for the denial from the plan's representative in writing. If the representative is unresponsive, demand to talk to a supervisor. Always move up the plan's chain of command when you meet resistance.
Why was my coverage denied?

It is important for you to find out why your care was denied. Be sure to get the reason for the denial in writing. If your health plan claims the care is not a covered benefit, you should explain to them why you disagree with the decision. If you understand that the treatment is not covered, you may want to talk to your employer about changing your benefit coverage.

If another treatment has been suggested or your requested treatment has been deemed not "medically necessary," you will need to advocate aggressively for the desired treatment. You should research your condition and treatment options on your own so that you have strong explanations for why your requested treatment is necessary.

WHAT IS MY HEALTH PLAN'S TIMELINE FOR RESOLVING MY GRIEVANCE?

Your health plan must resolve your grievance within 30 days whenever possible.³ Your plan must also provide you with a written statement regarding the status of the grievance no later than 3 days from when the company receives the grievance.⁴

WHAT IS THE TIMELINE FOR RESOLVING MY GRIEVANCE IN AN EMERGENCY CASE OR WHERE A SERIOUS THREAT TO MY HEALTH IS INVOLVED?

In an emergency case, you do not have to participate in the plan's grievance process, but rather, you can submit your grievance directly to the Department of Managed Health Care.

Your health plan must have a quicker grievance process for emergency cases or when a serious or imminent threat to your health exists, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function.⁵ When your plan is told that your case requires a speedier review, the grievance system requires the plan to immediately inform you in writing of your right to notify the Department of Managed Health Care of the grievance. Your plan must also notify you and the Department within three days from when it received your grievance of it's decision or the pending status of your grievance.⁶ Medicare rules similarly require that grievances be resolved within 72 hours when there is a serious threat to life or health.

WHEN MAY I SUBMIT A GRIEVANCE TO THE DEPARTMENT OF MANAGED CARE (DMHC)?

The DMHC may require that you participate in your health plan's grievance process for 30 days, unless your case involves a serious threat to your health or some other circumstance where the DMHC determines that an earlier review is needed.⁸

After you have either completed your plan's grievance process or been in the process for 30 days without resolution, you may submit your grievance to the Department of Managed Health Care for review by completing a "Consumer Complaint Form."⁷ (A copy of this form is included as Appendix A at the end of this guide, or you can complete the at: http://www.dmhc.ca.gov.) Your plan must inform you of this right.

WHAT IS THE DEPARTMENT OF MANAGED HEALTH CARE'S TIMELINE FOR RESOLVING MY GRIEVANCE?

Generally 30 days. The Department of Managed Health Care must review the written documents you submit along with your DMHC "Consumer Complaint Form." The DMHC may ask for additional materials from you and may hold meetings with the parties involved, including your doctors.⁹ The DMHC must then send you, whoever is assisting you, and your health plan, a written notice of the Department's final decision on your grievance, along with reasons for the decision.

The Department of Managed Health Care has 30 days from when it receives your request for review to issue its final decision, unless the Director decides that additional time is needed.¹⁰

If your grievance has remained unresolved for 30 days, you may call the Department of Managed Health Care for assistance at (888) HMO-2219 or TDD (877) 688-9891

REMEMBER: You can use health plan's and the Department of Managed Health Care's grievance review processes in addition to any other dispute resolution procedures that may be available to you. You can still pursue other legal remedies that may be available to you without having to complete your plan's grievance process.

CAN THE DEPARTMENT OF MANAGED HEALTH CARE PENALIZE MY HEALTH PLAN FOR NOT COMPLYING WITH THE GRIEVANCE STANDARDS?

Yes. The Director of the DMHC may impose a penalty on your plan when your plan has repeatedly failed to follow the grievance standards. The Director must periodically evaluate patient complaints to find out whether the plans are complying with the grievance standards, and must then notify the plan and provide an opportunity for a hearing before fining the plan.¹²

WHERE CAN I GO FOR HELP?

If you are a Medi-Cal members, contact the Department of Health Services' Medi-Cal Managed Care Ombudsman at (888) 452-8609 for help with your grievance.
If you are a Medicare member, contact HICAP (Health Insurance Counseling & Advocacy Program) at (800) 824-0780 for more information about your rights to file grievances.
For assistance with the Department of Managed Health Care's grievance review process, call 1-800-HMO-2219 or TDD (877) 688-9891. A copy of the Department's "Consumer Complaint" form is included as Appendix A in this guide or you can fill it out online at www.dmhc.ca.gov/gethelp/complaint.asp

FOOTNOTES

Cal. Health & Safety Code §1368(a)(1).
Cal. Health & Safety Code §1368(a)(2).
Cal. Health & Safety Code §1368.01(a).
Cal. Health & Safety Code §1368.01(b).
Cal. Health and Safety Code § 1368.01(b).
Cal. Health and Safety Code § 1368.01(b).
Cal. Health and Safety Code § 1368(b)(1)(A).
Cal. Health & Safety Code §1368.03.
Cal. Health & Safety Code §1368(b)(3).
Cal. Health & Safety Code §1368(b)(5).
Cal. Health & Safety Code §1368.04.