CMA - California Medical Association

If you have a problem with your health plan, you have the right to file a complaint. A complaint is also called a grievance or an appeal. The rules and procedures for filing a complaint will vary based on the type of plan. Below you will find instructions on filing complaints about HMOs and other Knox Keene plans, PPOs, and Medicare.

We hope this information is helpful to you. CMA is unable to provide individual legal advice. For a legal opinion concerning a specific situation, consult your personal attorney. More in depth information about your rights is available in CMA’s medical-legal document # 1049, “Patient Complaints about Health Plans.”

Patient Grievances with HMOs (Knox-Keene Plans)

The Department of Managed Health Care (DMHC) regulates all HMOs, plus Blue Shield of California and Blue Cross of California plans. These plans are subject to regulation under the Knox-Keene Act.

If you have a complaint about a Knox-Keene plan, the first step is to use your health plan's grievance process. Every Knox-Keene plan is required by law to maintain a grievance system for patient complaints. Every plan with a website must also provide a form where subscribers and enrollees can file complaints online. The form must be easily accessible through a hyperlink from the home page or member services portal and be clearly identified as "grievance form." You can also initiate a complaint by calling your health plan at the number provided on your insurance card. (DMHC provides contact information for all plans that it licenses on its website.)

Plans must resolve patient grievances within 30 days of receipt, unless the case involves an imminent and serious threat to the health of the patient. Cases involving an imminent and serious threat to the health of the patient, including but not limited to those involving severe pain, or potential loss of life, limb or major bodily function, must be resolved within 3 days, and a written statement on the disposition of the grievance must be provided within that time frame to both the enrollee and DMHC.

If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan’s internal system, or a grievance that has remained unresolved for more than 30 days, you may contact DMHC for assistance. If your complaint involves immediate and serious threat to your health, you should immediately contact the DMHC HMO Help Line at (888) HMO-2219, TDD (877) 688-9891. You can authorize your physician to assist you in a grievance before DMHC.

You can also contact DMHC by mail at:

Patient Grievances with Health Insurers

PPOs (except Blue Cross and Blue Shield PPOs) and other non-HMO insurers are regulated by the Department of Insurance (DOI). DOI investigates complaints, prosecutes insurers when appropriate and responds to complaints and inquiries by members of the public concerning the handling of insurance claims or alleged misconduct by insurers.

If you have a complaint about a health insurer, the first step is to contact the insurance company in an effort to resolve the issue. If you need help with a grievance involving an emergency or that has not been satisfactorily resolved by your insurer, you may contact DOI for assistance.

DOI has a toll-free number dedicated to the handling of complaints and inquiries, (800) 927-HELP (4357), TDD (800) 482-4833. DOI also provides a simple, standardized online complaint form, the Consumer Request for Assistance. The form may be submitted online (if there is no supporting documentation) or by mail to:

Medicare Patient Grievances

Medicare patients are entitled to special grievance and appeal rights. Medicare HMOs, competitive medical plans, and health care prepayment plans are required by law to give you a complete written explanation of your grievance and appeal rights. Medicare also maintains a website, http://www.medicare.gov, that is very helpful. Information on appeals can be found at http://www.medicare.gov/basics/appeals.asp.

The California Department of Aging also provides understandable, comparative information about Medicare health plans through its Health Insurance Counseling and Advocacy Program (HICAP). HICAP provides free and objective information and counseling about Medicare.

For more information on the rules specific to denials of care under Medicare Managed Care, see CMA medical-legal document #1026, "Denials Under Medicare Managed Care."

In an Emergency

HMOs/Knox Keene Plans: If you are in a situation where your health is seriously threatened and you need fast assistance in dealing with a health plan problem, you will want to inform your plan and call the DMHC Help Line right away at (888) HMO-2219 or TDD (877) 688-9891.

Health Insurers: If you have traditional insurance, call the California Department of Insurance at (800) 927-4357 and explain your situation. If necessary, they will contact your insurance company by phone to resolve your complaint, instead of going through their usual process, which commonly takes from 30 to 90 days.

Patient Assistance Programs

There are several programs offering assistance to consumers who need help navigating the current health care system. The health care consumer assistance programs can be contacted as follows:

(213) 383-4519; FAX (213) 383-4598
Toll-free in Los Angeles County: (800) 824-0780
Health Consumer Alliance

Phone: (310) 204-4900
Fax: (310) 204-0891
http://www.healthconsumer.org

Regional Offices
Fresno: (800) 300-1277
Imperial: (760) 353-0220
Kern: (661) 321-3982
Los Angeles: (800) 896-3203
Orange: (800) 834-5001 or (714) 571-5200
Sacramento, El Dorado Placer & Yolo: (888) 354-4474
San Diego: (877) 734-3258
San Francisco: (415) 982-1300
Alameda: (510) 663-4744
San Mateo: (800) 381-8898 or (650) 558-0915; TDD (650) 558-0786

Health Insurance Counseling and Advocacy Programs (Medicare Only)

http://www.cahealthadvocates.org/hicap
Phone: (800) 434-0222

Department of Managed Health Care

Phone: (888) HMO-2219
Fax: (916) 229-0465
TDD: (877) 688-9891
helpline@dmhc.ca.gov
http://www.dmhc.ca.gov

Claims Appeals Process Required Under Federal Health Care Reform

Federal health care reform, enacted by the Patient Protection and Affordable Care Act (PPACA), establishes a national standard requiring all health plans and insurers to implement internal claims appeals processes. The federal law does not supersede or preempt state laws if the state laws do not conflict. In other words, state laws can go further than the patient protections required under PPACA.

PPACA requires all health plans and insurers to implement an effective process for appeals of coverage determinations and claims that includes, at a minimum:

• An established internal claims appeal process;
• Notice to participants in a "culturally and linguistically appropriate manner" of available internal and external appeals processes, including the availability of assistance with the appeals processes; and
• A provision allowing an enrollee to review his or her file, to present evidence and testimony as part of the appeals process, and to receive continued coverage during the appeals process.

The Secretary of Health and Human Services is expected to issue implementing regulations further detailing these requirements.