Grievances and Appeals
CenCal Health values your satisfaction. This means we want to know when you believe the quality of care or services you received did not meet your expectations. Member Satisfaction is measured in several ways. One way we do this is through grievances and appeals. We need to hear from you if you are not happy with the care or service provided by your provider or Health Plan.
Within the Member Grievance and Appeal System, CenCal Health staff assist members with filing grievances (complaints) and appeals (disagreements with the Plan’s decisions), to ensure members’ rights are protected and their right to grieve is provided without retaliation or discrimination.
To view CenCal Health’s policies and procedures for grievances and appeals please click on any of the policy links below for more information:
If you have a grievance about a doctor’s medical treatment, care, or access to care or services, our first priority is to place you in a situation where you are comfortable with the care you are receiving. If this happens, a Member Services Representative can help you choose a new doctor. You may file a grievance verbally at 1-877-814-1861, in writing, or through this website at the following link: On-Line Grievance Form (in English and Spanish). Or, if you cannot hear or speak well, please call TTY: CA Relay at 711.
To download/print a Member Grievance Form to submit by fax or mail:
Select the links below for a copy of a Member Grievance Form in English or Spanish:
Member Grievance Form – English
Member Grievance Form – Spanish
For filing by mail, please send your grievance to the address below:
CenCal Health
Attention: Grievance and Appeals Coordinator
4050 Calle Real
Santa Barbara, CA 93110
To fax, please send your grievance to:
CenCal Health, Attention: “Grievance and Appeals Coordinator” at 1-805-692-1684.
If you would like your provider to file a grievance on your behalf, your provider must obtain verbal consent directly from you to do so. CenCal Health is able to initiate a grievance filed by a provider for a member, with at the least, verbal consent from the member. CenCal Health requires members to provide verbal consent, so it is best to obtain this authorization for submission when filing the grievance request. Copies of these forms are available at the following links:
Written Consent Grievance Form – English
Written Consent Grievance Form – Spanish
You can file a grievance anytime. However, we encourage you to file as close as possible to the date of the incident causing your dissatisfaction in order for CenCal Health to investigate your concerns. Your concern will be reviewed by the appropriate Plan staff, which includes a physician reviewer when a clinical issue, such as quality of care, is your concern. You will be notified when the review is completed, no later than 30 calendar days from your complaint.
If CenCal Health has denied you a requested service and you disagree with this decision, you may file an appeal. You may file an appeal verbally by calling our Member Services Department at 1-877-814-1861, in writing, or through our website within 60 days (2 months) from the date of the decision.
The Health Plan’s review will be conducted by a physician reviewer who was not involved in the original decision. Your appeal will be completed no later than 30 calendar days from the date you filed your appeal. You may file an appeal verbally at 1-877-814-1861, in writing, or through this website at the following link: On-Line Grievance Form (in English and Spanish). Or, if you cannot hear or speak well, please call TTY: CA Relay at 711.
To download/print a Member Appeal Form to submit by fax or mail:
Select the links below for a copy of a Member Appeal Form in English and Spanish:
For filing by mail, please send your appeal to the address below:
CenCal Health
Attention: Grievance & Appeals Coordinator
4050 Calle Real
Santa Barbara, CA 93110
To fax, please send your appeal to:
CenCal Health, Attention: “Grievance & Appeals Coordinator” at 1-805-692-1684.
If you would like your provider to file an appeal on your behalf, your provider must obtain written consent from you to do so. This signed consent should be submitted with your appeal request. CenCal Health is only able to initiate an appeal filed by a provider for a member, with written consent from the member. DHCS requires CenCal Health to request written consent even if verbal authorization is obtained, so it is best to obtain written authorization for submission when filing the appeal request. Copies of these forms are available at the following links:
Written Consent to Appeal Form – English
Written Consent to Appeal Form – Spanish
If you feel that CenCal Health denied you a requested service that poses an urgent or serious threat to your health, you may ask for an expedited (faster) appeal by calling a Member Services Representative at 1-877-814-1861. Or, if you cannot hear or speak well, please call TTY: CA Relay at 711.
An urgent or serious threat means you believe your life is at risk, you may lose a limb or have serious impairment to bodily function or will be experiencing severe pain.