File a Grievance (Complaint) or Appeal
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 and one of them is needing 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 & Appeal System, CenCal Health staff assist members with the filing of grievances (complaints) and appeals (disagreement 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:
1. Grievances
2. Appeals
3. Communication and Education
4. Monitoring and Oversight
5. Definitions
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 California Relay at 711 or TTY: 1-833-556-2560.
To Download/Print a Member Grievance Form to submit by fax or mail:
Please click the links below for a copy of a Member Grievance Form in English or Spanish:
For filing by mail, please send your Grievance to the address below:
To Fax, please send your Grievance to:
CenCal Health, Attention: “Grievance and Appeals Coordinator” at 1-805-692-1684.
If you would like for your provider to file a grievance on your behalf, providers 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 on 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 to the date of the incident causing your dissatisfaction as possible in order to be able 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 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 California Relay at 711 or TTY: 1-833-556-2560.
To Download/Print a Member Appeal Form to submit by fax or mail:
Please click 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 for your provider to file an appeal on behalf of a member, providers 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 on 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 California Relay at 711 or TTY: 1-833-556-2560.
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.