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How to File a Complaint or Appeal
At any time you may continue the process of submitting a complaint or appeal by clicking the "Back" button on your browser, or by clicking here.
Complaints
If you have a complaint about a doctor's medical treatment or care, our first priority is to place you in a situation where you are comfortable with the care you are receiving. Therefore, if you complain or have concerns about the doctor you have chosen (or we have chosen for you) our Member Services Representative may first try to place you with another doctor, if you wish. Your complaint should include specific information about your concern(s). Your quality of care concerns will be reviewed by a medical reviewer who has the education, training, and relevant expertise that is pertinent to evaluate the specific clinical issues noted in the complaint. When reviewing complaints relating to medical treatment, please be aware, California Law requires that the results of such investigation are confidential, even from the person filing the complaint. This process, called "Peer Review" will review all aspects of the complaint regarding medical care and determine whether or not a doctor acted in a reasonable fashion given the circumstances. Members will be notified in writing should the Health Plan review complaints through this process.
At any time following the resolution of a member's complaint, member may present feedback to
CenCal Health's Community Advisory Board regarding any dissatisfaction with the Heatlh Plan's Grievance System.
Appeals
If your doctor, specialty doctor or Health Plan (CenCal
Health) has denied you a requested service and you disagree with this decision, you may file an appeal by calling our Member Services Department at the telephone number listed. We will send you a letter within five (5) calendar days telling you we have received your appeal.
The Health Plan will review and resolve all complaints and appeals within (30) calendar days of the Health Plan's receipt of the complaint.
Expedited Appeals
If you feel that your doctor, specialty doctor or Health Plan (CenCal
Health) has denied you a requested service that poses an urgent or serious threat to your health, (an urgent or serious threat is considered potential loss of life, limb, major bodily function, or severe pain) you may ask for an expedited (faster) appeal by calling a Member Services Department. If your appeal meets the criteria for expedited (faster) appeal, you will receive a resolution to your expedited appeal within seventy-two (72) hours. If your appeal does not meet the criteria for expedited review, we will send you a letter within five (5) calendar days telling you we have received your appeal and it will be resolved within thirty (30) calendar days.
External Review / Independent Medical Review
You may request an Independent Medical Review if you were denied a service based on medical necessity, or the service is considered experimental / investigational and/or you have a life-threatening or seriously debilitating condition. Cases relating to eligibility, claims, billing and covered benefits are not eligible for External Review.
CenCal Health retains the responsibility of determining if a dispute is related to medical necessity, or whether or not a treatment is experimental or investigational.
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