How to File a Grievance or Appeal

Filing a Grievance or Appeal

As a CalOptima 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 1-714-246-8500 or toll-free at 1-888-587-8088.

You also have the right to file a complaint if you are not happy with the care, service or treatment you received. You can file a complaint at any time that caused your dissatisfaction by:

  • Filling out the Online Member Grievance or Appeal form and click the “Submit” button for a secure online submission.

  • Calling the Customer Service Department at 1-714-246-8500 or toll-free at 1-888-587-8088; or

  • Coming into our office at 505 City Parkway West, Orange, CA 92868; or

  • Filling out the Printed Member Complaint Form or writing a letter to CalOptima and sending the letter to 505 City Parkway West, Orange, CA 92868.

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 seventy two (72) hours 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 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.

Notice of Right to Medi-Cal Fair Hearing:

CalOptima Members have a right to ask for a Medi-Cal State Hearing (SH) after you submit your appeal to CalOptima and you still do not agree with the decision.

The hearing request must be filed with the State within 120 days of the date of the appeal decision or action the Member is unhappy about.

Members may call CalOptima Customer Service toll-free at 1-888-587-8088 for help or call the Department of Social Services Public Inquiry and Response Unit at 1-800-952-5253, to ask for a SH.

For the hearing impaired only: 1-800-952-8349.

Members may also ask for a SH by mail at the following address:

California Department of Social Services, State Hearing Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430

 

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