Health plan members, also known as enrollees should file a complaint (also known as an appeal or grievance) if you have a problem with your health plan. To do so, first contact your health plan to file a complaint. You can file a complaint with your health plan over the phone or in writing. You may also be able to file a complaint on your health plan's website.
If your health problem is urgent, if you already filed a complaint with your health plan and are not satisfied with the decision, or it has been more than 30 days since you filed a complaint with your health plan you may submit an Independent Medical Review Application/Complaint Form with the DMHC. If you need assistance you may contact the Help Center at 1-888-466-2219.
Enrollees can file a Consumer Complaint with the DMHC for complaint issues such as balance billing, billing for services that your health plan states is not a covered benefit, if you have a dispute on the amount paid on a claim, a co-pay dispute, cancellation of your coverage or if you have a complaint about the provider’s attitude.
Enrollees can also apply for an Independent Medical Review (IMR) with the DMHC when a health care service or treatment has been denied, modified or delayed. An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service or treatment you need by requesting an IMR. If the IMR is decided in your favor, your plan must authorize the service or treatment you requested. IMR’s are free to enrollees.
For your convenience, both of these complaint types can be submitted to the DMHC on one Independent Medical Review Application/Complaint Form.
Enrollees can submit a Consumer Complaint or request an IMR using the Independent Medical Review Application/Complaint Form.
Need help? Call the DMHC Help Center at 1-888-466-2219 or send us an email