HomeFile a Complaint

How to File a Complaint

File a Complaint

 Independent Medical Review & Complaint Process

 

 How to Apply

 

 Authorized Assistant Form

 

 What Happens Next

 

 Frequently Asked Questions

 
 

Independent Medical Review & Complaint Process

If your health plan denies, changes or delays your request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment for a serious medical condition, you can apply for an Independent Medical Review (IMR).

You can also file a Consumer Complaint when you have other issues with your health plan. These issues can consist of billing problems, cancellation of coverage, claim and copay disputes, delays in getting an appointment, referral or authorization, access to translation services, finding an in-network doctor, hospital, or specialist, complaints about a doctor or plan and continuity of care.

For more information about IMR and Consumer Complaints, please visit our Frequently Asked Questions.

 

How to Apply

STEP 1: File a Grievance/Complaint with Your Health Plan

Before filing an Independent Medical Review (IMR)/Complaint with the DMHC, you are first required to File a Grievance/Complaint with Your Health Plan.

Health plans are required by law to have a grievance process in place to resolve enrollee complaints within 30 days. In most circumstances, you are required to file a grievance regarding each issue/request with your health plan and participate in the process for 30 days before submitting a complaint to the DMHC. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational. In either of these instances, you may seek immediate assistance from the DMHC.

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.

 

STEP 2: File an IMR/Complaint with the DMHC

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.

 

A graphic of a laptop

Submit IMR / Complaint Form

English Español

 

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.

 

Authorized Assistant Form

If you want to give another person permission to help you with your Independent Medical Review (IMR) or Complaint, use the form below. You have the option to send the form either as an attachment with your online IMR/Complaint Form, or with your supporting documents by mail or fax.

We cannot talk to another person about your case unless you sign this form:

Authorized Assistant Form (English), Formulario de Asistente Autorizado (Español)

 

What Happens Next

  • Within 7 Days
    The Help Center will review your application and send you an acknowledgement of receipt letter.

    Expedited IMR decisions are typically determined, if the case has qualified for an IMR and the required documentation has been received by the DMHC's Independent Medical Review organization.
  • Within 30 Days

    Consumer Complaints are usually decided.
  • Within 45 Days

    Non-expedited IMRs are usually decided.

 

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)