Member Grievance and Appeal Process
Members have the right to initiate the Grievance or Appeals process through their health plan. Most health plans have an option to call member services, fill out a form on their website, or complete a hard copy form. Updated Medi-Cal health plan forms are available below for your convenience.
Appeals
- Members can file an Appeal with their health plan up to 180 calendar days following receipt of a denial notice.
- An Appeal is when the member doesn't agree with the decision not to cover or change your services.
- The request will be acknowledged within five calendar days of receipt and resolved within 30 calendar days.
Grievances
- Members can file a Grievance with their health plan any time following an incident where there was dissatisfaction.
- A Grievance is when the member has a problem with the health plan or a provider, or with the health care or treatment received from the provider.
- The form should include the specific details of the problem and dates of the event.
- The form and all relevant documents should be sent to the health plan as described.
- The request will be acknowledged within five calendar days of receipt and resolved within 30 calendar days.
- If the Grievance is urgent, please call the health plan member services department listed on the Member ID card.
Examples of urgent requests include:
- Imminent and serious threat to the member's health, including but not limited to severe pain and/or potential loss of life, limb, or major bodily function.
- Concerns related to cancellation, rescission, or nonrenewal of coverage.
