If you are a CalOptima Healthy Families Program member, we want to hear your concerns about the health care services you get. We want you to talk with your doctor or health network if you have any questions about your health care. If this is not possible, or you need help, please call the CalOptima Customer Service Department at 1-800-530-2899.

You also have the right to file a complaint if you are not happy with the care, service or treatment you got. You can file a complaint within 180 calendar days of the incident that caused your dissatisfaction by:

After CalOptima receives your complaint, we will send you a letter within five (5) calendar days letting you know the status of your complaint and the name of a Resolution Specialist to call with any questions. If you send the form electronically during non-business hours, the notice will be sent to you no later than five (5) calendar days from the next business day. A letter explaining the response to your complaint will be mailed within 30 days of getting your complaint.

Rushed Matters: Any complaint with serious health concerns will be reviewed by CalOptima within three (3) days of getting the complaint.

You may also call the CalOptima Fraud Hotline at 1-877-837-4417 to report any action you think may be fraudulent, such as when a doctor or pharmacy asks you to pay more than proper for an office visit or medicines, or if you see someone using another person’s Medi-Cal or Healthy Families card. You do not have to give your name to report fraud activity.

CalOptima will not discriminate against you or limit your benefits in any way if you express concerns or file a complaint.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-530-2899 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department' s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.