Grievance and Complaint Form

If you would like to file a grievance/complaint against your Insurance Plan, please complete the form below. We will attempt to resolve all grievances/complaints as soon as possible. If you need any help completing this form, please call us at 1-833-444-6682. The Department of Managed Health Care is responsible for regulating health care service plans in California. If you have a grievance against your health plan, you should first telephone your health plan at 1-833-444-6682 and use your health plan‘s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department‘s Internet Web site www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.