Health plan members, also known as enrollees should file a complaint (also known as an appeal or grievance) if you have a problem with your health plan.
To do so, first Contact Your Health Plan to File a Complaint
You can file a complaint with your health plan a few different ways:
- Over the phone
- In writing
- Through your health plan's website (if available)
If your health problem is urgent, if you already filed a complaint with your health plan and are not satisfied with the decision, or it has been more than 30 days since you filed a complaint with your health plan you may submit an Independent Medical Review/Complaint Form with the DMHC.
What is an Independent Medical Review?
Enrollees can apply for an Independent Medical Review (IMR) with the DMHC when a health care service or treatment has been denied, modified or delayed.
An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service or treatment you need by requesting an IMR.
If the IMR is decided in your favor, your plan must authorize the service or treatment you requested. IMR’s are free to enrollees.
What is a Consumer Complaint?
Consumer Complaints include issues such as:
- Balance billing
- Billing for services that your health plan states is not a covered benefit
- Disputes on the amount paid on a claim
- A co-pay dispute
- Cancellation of your coverage
- A complaint about the plan or provider’s attitude or quality of care
For your convenience, both of these complaint types can be submitted to the DMHC on one Independent Medical Review/Complaint Form.
Need help? Call the DMHC Help Center at 1-888-466-2219 or Send Us an Email