How to File a Complaint

How to Apply

Before you can file an Independent Medical Review (IMR)/Complaint with the DMHC, you must first file a Grievance/Complaint with your Health Plan. 

You are required to file a grievance regarding each issue/request with your Health Plan and participate in their grievance process for 30 days before submitting a complaint to the DMHC. You may, however, seek immediate assistance from the DMHC if there is a serious threat to your life or your request was denied by your Health Plan as being experimental or investigational. 

Find Your Health Plan's Member Services Phone Number or Website

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 Health Plan's website. Your Health Plan membership card has a member services phone number listed on the card. You can call that number if you want to file a complaint (grievance or appeal).

You can also find your Health Plan's member services contact information by selecting the "View All Health Plans" link below.

View All Health Plans

You can file a complaint with the Help Center if you are not satisfied with your Health Plan's decision or if you have not received your Health Plan's decision within 30 days.

Once you have participated in the 30-day process with your health plan, if the issue has not been resolved or you are not satisfied with the decision, you can proceed with filing an IMR/Complaint with the DMHC. If your health problem is urgent, you may seek immediate assistance from the DMHC.

For your convenience, an IMR and Complaint can be submitted to the DMHC on one IMR/Complaint form.

Submit IMR / Complaint Form

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You have the option to submit your IMR/Complaint form in many languages by mail or by fax. Be sure to complete all fields, include any copies of supporting documents and sign the form.

You filed a complaint/IMR with the DMHC. What Happens Next?

Your complaint/IMR must go through all three stages below before the DMHC can provide you with an update on the status of your complaint or IMR. The DMHC staff will not have specific information until the minimum handling timeframe has passed on your case. Generally, these stages take a minimum of 30 days for a complaint, or 45 days for an IMR. If more information is required from you, the DMHC staff working on your complaint/IMR will contact you by phone or email.

Complaints and IMRs are handled in 3 stages:

Stage 1: Complaint/IMR Intake and Processing

• The DMHC creates a case for your complaint/IMR.
• The DMHC sends you an acknowledgement letter with a case number once your case enters this stage.
• During this stage we contact the health plan you listed on your complaint to:
  • Make sure your health plan is licensed by the DMHC. If your plan is not licensed by the DMHC, we will close your case and direct you to the appropriate department or agency for assistance.
  • Confirm that you have already completed the grievance/appeal process with your health plan (this is required in most instances). We will close your case if you have not completed your health plan’s grievance/appeal process. You may file a new complaint/IMR with the DMHC if your health plan does not respond to your grievance/appeal within 30 days or you are not satisfied with your health plan’s response to your grievance/appeal.
  • Require your health plan to answer our questions and provide us with all information related to your case.

Stage 2: Information Gathering and Review

• Once the DMHC receives all required information from you and your health plan, the information will be reviewed.
  • The DMHC will only send you a request if more information is required. If you send the DMHC more information the DMHC did not request, it may extend the amount of time it takes the DMHC to review your complaint/IMR.
  • If we have everything we need, the DMHC will not contact you until we issue a determination.

Your complaint/IMR may require additional review by an independent medical expert, DMHC attorneys and/or DMHC clinical staff. This may extend the time it takes to review your complaint/IMR.

Stage 3: Determination

• When the review of your complaint/IMR has been completed, the DMHC will send you a determination letter. Please note, the DMHC does not accept appeals of the determination. If you have a new issue or your medical condition changes, you may be required to submit a new complaint/IMR to the DMHC. See possible determinations.

How long will the complaint process take?

Please note: the following are general timeframes and are not guaranteed. Many factors may require additional time to process your complaint/IMR to ensure a thorough review.

• Complaints are generally determined within 30 days from the date of receipt.
• IMR cases are generally determined within 45 days from the date the case qualifies for an IMR.
• All cases are screened for possible expedited handling. If your case is expedited, handling times may be shorter than 30 days for a complaint or 45 days for an IMR. Expedited cases are those involving an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function. (Knox Keene Act)

Possible determinations include, but are not limited to:

• Approval/Health Plan Reversal: After receiving your complaint, the health plan may reverse its denial and approve the service(s) you requested.
• Partial Approval: After receiving your complaint, the health plan reverses a portion of its denial and approves a portion of the service(s) you requested.
• Denial: The DMHC has determined the health plan’s denial complies with its obligations under the Knox Keene Act.
  • Return to Plan: The health plan may state that all or a portion of your grievance/appeal is new and has not completed the health plan’s required grievance or appeal process (§ 1368.03).
  • Non-jurisdictional: During review, if the DMHC does not have jurisdiction over your health plan, we will close your case. The DMHC closing letter will inform you who does have jurisdiction over your health plan and how to contact them.
  • Informational: An informational closure is issued when it is necessary to provide you with additional details, clarification, or guidance on your rights and next steps.
  • Closed – No response: We may contact you because more information is needed to process your case, and if we are unable to reach you after several days, we may close your case.
  • Closed – Duplicate: A case will be closed if it is a duplicate of a prior case submitted to the DMHC and no new information has been provided.
  • Upheld: If your case qualified for independent medical review (IMR), this means the independent medical review organization agrees with your health plan’s denial and the denial is being upheld.
  • Overturned: If your case qualified for IMR, this means the independent medical review organization does not agree with your health plan’s denial and the denial is overturned. The health plan is now required to authorize the services you requested.
  • Partially Overturned: If your case qualified for IMR, this means the independent medical review organization does not fully agree with your health plan’s denial and the denial is partially overturned and some of the service(s) you requested are now required to be authorized by your health plan. Please note the determinations can be a combination of the above options (partial approval and denial, etc.).

Important Information

After you have submitted a complaint or requested an Independent Medical Review through the DMHC Help Center, the DMHC will communicate important information about your case through protected messages (encrypted) to safeguard your privacy. Visit the Protected Messages page to learn more.

Have additional questions? Take a look at our Frequently Asked Questions.

Other helpful links:

Independent Medical Review and Complaint Reports

Provider Complaint Against a Plan

Legal Representative for Deceased Patient Form (English)