Wednesday, September 9, 2026
California fines Blue Shield of California $800,000 for delaying resolution of member complaints
WHAT YOU NEED TO KNOW:
- Blue Shield of California responded inadequately to DMHC inquiries causing delays for members, including members seeking medically necessary care.
- Health plans must meet deadlines and provide information promptly to allow the DMHC time to thoroughly review member complaints.
- Health plan members have a right to appeal health plan decisions and file a complaint with the DMHC when they don’t agree with their plan’s response.
SACRAMENTO - The Department of Managed Health Care (DMHC) fined California Physicians’ Service (Blue Shield of California) $800,000 for grievance system failures that delayed DMHC’s resolution of member complaints. The plan repeatedly submitted late or incomplete responses to DMHC inquiries, impacting 58 member complaints, also called grievances or appeals.
“Blue Shield of California failed to properly respond to DMHC inquiries regarding member complaints filed with the DMHC Help Center, which can lead to delays in medically necessary care for members,” said DMHC Director Mary Watanabe. “Health plans must meet deadlines and promptly provide complete information to ensure timely resolution of member complaints.”
PROTECTIONS FOR HEALTH PLAN MEMBERS: California law requires health plans to have a grievance and appeal system to review, resolve and respond to member complaints in an appropriate and timely manner. Through the grievance system, health plans inform members of their grievance and appeal rights and protections under the law, including the right to file a complaint with the DMHC if the member does not agree with their health plan’s decision or the plan takes more than 30 days to respond to a member complaint.
California law requires health plans to provide information on member complaints to the DMHC and respond to Department questions within five calendar days. In this case, Blue Shield of California failed to timely and adequately respond to the DMHC’s request for information in 121 instances from May 2024, through December 2024, which hindered the ability of the DMHC to evaluate the members’ issues. In addition to the fine, Blue Shield of California has agreed to a corrective action plan and will train its staff to respond timely to Department requests for information.
WHAT MEMBERS NEED TO KNOW: The DMHC encourages health plan members experiencing issues with their health plan, including denials of payment for covered health care services, to file a complaint with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to respond to the complaint, the member can contact the DMHC Help Center. If a health plan member is experiencing an urgent issue, they can contact the DMHC Help Center immediately. Health plan members can file a complaint with the DMHC Help Center at www.DMHC.ca.gov or by calling 1-888-466-2219.
MORE INFORMATION: More information about Blue Shield of California can be found on the health plan dashboard on the DMHC website, including information on the plan’s service area, enrollment and complaints.
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About DMHC
The mission of the DMHC is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system. The DMHC accomplishes this important mission by regulating health plans, enforcing California’s strong consumer protection laws and assisting health plan members. For more information visit www.DMHC.ca.gov.