You have a right to get the health care you need through your HMO or health plan. You have a right to file a complaint if you cannot get the care you need.

For example:

• Did your health plan say you cannot get a treatment or medicine you need?
• Are you dissatisfied with the medical care you receive or the way you are treated?
• Are you having a problem getting a doctor’s appointment or a doctor referral when you need it?
• Did you get a bill for care your health plan should pay for?

If you have a problem with your health plan, follow these 3 steps:

Step 1: Talk to Your Doctor and Your Health Plan

• Ask your doctor what he or she thinks you should do, and how the doctor can help you.
• Contact your health plan by calling the member services phone number listed on your membership card, and explain the problem to see if it can be resolved.

Step 2: File a Grievance with Your Health Plan

• Call your health plan’s member services office at the number listed on your membership card.
• You may file the grievance over the phone or in writing. You will need to explain the problem and the date it occurred. If you were denied medical care, you must explain why you need it, and if the need is urgent, explain why.
• You may only have a limited time to file a grievance with your health plan from the date the action you disagree with occurred.

Step 3: Call the Department of Managed Health Care (DMHC) to file a complaint or request an Independent Medical Review (IMR)

You can contact the DMHC’s HMO Help Center at 1-888-466-2219. Some forms and answers can also be found at the website www.hmohelp.ca.gov.

• File a complaint with DMHC: Generally, before appealing to the DMHC you must first file a grievance with your health plan and wait the 30 days for a standard grievance or 3-5 days for an expedited grievance (in cases of possible loss of life or limb, or severe pain). If you are not satisfied with your health plan’s response to your grievance, you may file a complaint with the DMHC for most problems.
• File a request for an Independent Medical Review (IMR) with DMHC: In an IMR, doctors and other health professionals who are not part of your health plan review your case and decide if your health plan must give you the treatment or services. You may request an IMR if:
  • You have been denied treatment or services because your health plan does not think they are medically necessary.
  • Your health plan refuses to pay for emergency services or out-of-plan urgent services that you have already received and are being billed for.
  • Your health plan is refusing to cover a treatment that your doctor has recommended because it considers it to be “experimental” or “investigational.” If you have been denied treatment because your health plan says it is “experimental” or “investigational,” you may go straight to DMHC and file a request for an IMR, without filing a grievance with your health plan.

See this Health Consumer Alliance brochure for more information about what to do if you have a problem with your HMO or health plan.

You can call the Health Rights Hotline for help at any time at (916) 551-2100 or toll free at (888) 354-4474.