Your Rights

As a CalOptima Health plan member, you have important rights and we take them seriously.

This page explains what you can expect from us, what we ask of you and how to get help when you need it.

Your Rights

Introduction

Your health and your voice matter. CalOptima Health is committed to treating every member with dignity, fairness and respect, and to making sure you have the information and support you need to get the most out of your coverage.

This page covers your rights and responsibilities as a member, how to file a grievance (or complaint), links to important forms, key documents, and required plan disclaimers. If you have questions about your rights, call CalOptima Health Customer Service at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m.

Rights and Responsibilities

As a CalOptima Health plan member, you have rights and responsibilities. Understanding both helps you get the best care possible and keeps your coverage running smoothly.

As a Member, You Have a Right to:

Receive information about your rights and responsibilities.
Receive information about your plan, the services your plan offers you, and the health care providers available to care for you.
Make recommendations regarding the plan’s member rights and responsibilities policy.
Receive information about all health care services available to you, including a clear explanation of how to obtain them and whether the plan may impose certain limitations on those services.
Know the costs for your care, and whether your deductible or out-of-pocket maximum has been met.
Choose a health care provider in your plan’s network, and change to another doctor in your plan’s network if you are not satisfied.
Receive timely and geographically accessible health care.
Have a timely appointment with a health care provider in your plan’s network, including one with a specialist.
Have an appointment with a health care provider outside of your plan’s network when your plan cannot provide timely access to care with an in-network health care provider.
Certain accommodations for your disability, including
- Equal access to medical services, which includes accessible examination rooms and medical equipment at a health care provider’s office or facility.
- Full and equal access, as other members of the public, to medical facilities.
- Extra time for visits if you need it.
- Taking your service animal into exam rooms with you.
Purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California.
Receive considerate and courteous care and be treated with respect and dignity.
Receive culturally competent care, including but not limited to:
- Trans-inclusive health care, which includes all medically necessary services to treat gender dysphoria or intersex conditions.
- To be addressed by your preferred name and pronoun.
Receive from your health care provider, upon request, all appropriate information regarding your health problem or medical condition, treatment plan, and any proposed appropriate or medically necessary treatment alternatives. This information includes available expected outcomes information, regardless of cost or benefit coverage, so you can make an informed decision before you receive treatment.
Participate with your health care providers in making decisions about your health care, including giving informed consent when you receive treatment. To the extent permitted by law, you also have the right to refuse treatment.
A discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Receive health care coverage even if you have a pre-existing condition.
Receive medically necessary treatment of a mental health or substance use disorder.
Receive certain preventive health services, including many without a co-pay, co-insurance, or deductible.
Have no annual or lifetime dollar limits on basic health care services.
Keep eligible dependent(s) on your plan.
Be notified of an unreasonable rate increase or change, as applicable.
Protection from illegal balance billing by a health care provider.
Request from your plan a second opinion by an appropriately qualified health care provider.
Expect your plan to keep your personal health information private by following its privacy policies, and state and federal laws.
Ask most health care providers for information regarding who has received your personal health information.
Ask your plan or your doctor to contact you only in certain ways or at certain locations.
Have your medical information related to sensitive services protected.
Get a copy of your records and add your own notes. You may ask your doctor or health plan to change information about you in your medical records if it is not correct or complete. Your doctor or health plan may deny your request. If this happens, you may add a statement to your file explaining the information.
Have an interpreter who speaks your language at all points of contact when you receive health care services.
Have an interpreter provided at no cost to you.
Receive written materials in your preferred language where required by law.
Have health information provided in a usable format if you are blind, deaf, or have low vision.
Request continuity of care if your health care provider or medical group leaves your plan or you are a new plan member.
Have an advance health care directive.
Be fully informed about your plan’s grievances procedure and understand how to use it without fear of interruption to your health care.
File a complaint, grievance, or appeal in your preferred language about:
- Your plan or health care provider.
- Any care you receive, or access to care you seek.
- Any covered service or benefit decision that your plan makes.
- Any improper charges or bills for care.
- Any allegations of discrimination on the basis of gender identity or gender expression, or for improper denials, delays, or modifications of trans-inclusive health care, including medically necessary services to treat gender dysphoria or intersex conditions.
- Not meeting your language needs.
Know why your plan denies a service or treatment.
Contact the Department of Managed Health Care if you are having difficulty accessing health care services or have questions about your plan.
To ask for an Independent Medical Review (IMR) if your plan denied, modified, or delayed a health care service.

As a Plan Member, You Have the Responsibility to:

Treat all health care providers, health care provider staff, and plan staff with respect and dignity.
Share the information needed with your plan and health care providers, to the extent possible, to help you get appropriate care.
Participate in developing mutually agreed-upon treatment goals with your health care providers and follow the treatment plans and instructions to the degree possible.
To the extent possible, keep all scheduled appointments, and call your health care provider if you may be late or need to cancel.
Refrain from submitting false, fraudulent, or misleading claims or information to your plan or health care providers.
Notify your plan if you have any changes to your name, address, or family members covered under your plan.
Timely pay any premiums, copayments, and charges for non-covered services.
Notify your plan as soon as reasonably possible if you are billed inappropriately.

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Grievance Forms

We make it easy to act when you need to. Below are direct links to the forms you may need as a CalOptima Health member.

Online Member Grievance Form

Printed Member Grievance Form

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Authorized Assistant Form

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Fraud, Waste and Abuse Reporting

You Can Report Fraud, Waste or Abuse Anonymously

If you see any activity that you think is fraud, waste or abuse, call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). You can also complete the online reporting form below. You do not have to give your name.

Compliance and Fraud, Waste and Abuse Reporting Form

Suspected Non-Compliance or Fraud, Waste and Abuse Reporting Form

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How to File a Grievance

CalOptima Health provides a fair and timely process for reviewing grievances, including coverage determinations and exception requests. If you have a concern or disagree with a decision we have made, here’s how to get help.

Grievances

A grievance is any expression of dissatisfaction about CalOptima Health and/or a health care provider, including quality of care concerns made by the member or their authorized representative. A grievance includes a complaint, dispute, request for reconsideration or appeal made by the member or their authorized representative.

The grievance can be made in writing or verbally. Except for quality of care complaints as described below, you must file your grievance within 180 calendar days from the day you became unhappy. These are some examples of reasons you might file a grievance:

You are not satisfied with the service, quality of care or how long it took to get care from your primary care provider (PCP), your PCP’s health network, or other health care providers, such as a hospital or pharmacy.
You are not satisfied with the service or care CalOptima Health gives you.
You believe you have faced discrimination from your PCP, your PCP’s health network, other health care provider, staff, or CalOptima Health.
You are not satisfied with how long it took to get covered benefits, including getting an appointment, or time in a waiting room or in the exam room.
You received a written denial, delay or modification of a service or a drug that requires prior authorization.
You received a written denial for a second opinion, or we did not respond to your request for a second opinion quickly, as appropriate for your condition.
You were told that the services are not a covered benefit, and you believe the services should be covered.
You want us to continue to cover an ongoing course of covered treatment.
We cancelled, terminated, rescinded or did not renew your membership and you disagree with that decision.
We declined your application for coverage, and you disagree with that decision.

How to File a Grievance

Write, visit or call CalOptima Health. You may also file a grievance online in English or in Spanish through CalOptima Health’s website at www.caloptima.org.
Call CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, 8 a.m.to 6 p.m. We have staff who speak your language.
Please contact CalOptima Health as listed below if you need a grievance form in a language other than Spanish or English, or in another format (such as large print or audio).

CalOptima Health
Customer Service
505 City Parkway West
Orange, CA 92868

1-888-312-2221 (TTY 711 if you are deaf or hard of hearing)

Urgent Grievances

If you want us to consider your grievance on an urgent basis, please tell us when you file your grievance that you are requesting an “expedited review.” An urgent grievance is a grievance that involves an imminent and serious threat to the mental or physical health of a member. An urgent grievance exists when there is an imminent and serious threat to your health, including but not limited to:

Severe pain
Potential loss of life, limb, or major bodily function
Serious jeopardy to your life, health, or ability to attain, maintain, or regain maximum function

We will call you about your grievance within 24 hours. CalOptima Health will make a decision within 3 calendar days from the day we received your urgent grievance. You may contact the California Department of Managed Health Care directly at any time, including if you believe your grievance qualifies for expedited review or if CalOptima Health does not respond within the required timeframe. You do not have to participate in CalOptima Health’s grievance process in order to file a complaint with the Department of Managed Health Care. Please see below for how to contact the Department of Managed Health Care.

Want Someone to Represent You?

If you want someone other than your doctor to represent you in an appeal or grievance, complete the Authorized Assistant form and include it with your submission.

Mail grievances, including appeals to:

CalOptima Health
Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868

Fax Number: 1-714-246-8562

Quality of Care Complaints

You can file a complaint about the quality of care provided by any CalOptima Health provider, hospital, emergency department, skilled nursing facility, home health agency or ambulatory surgical center. There is no specific deadline for quality-of-care complaints.

Quality of care issues include wrong medication, unnecessary surgery, diagnostic errors, inadequate care or misdiagnosis. Contact Grievance and Appeals Resolution Services or call CalOptima Health Customer Service toll-free at
1-888-312-2221 (TTY 711), Monday–Friday, from 8 a.m. to 6 p.m. for help with submitting a quality-of-care complaint. We have staff who speak your language.

Department of Managed Health Care Complaint Process

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 1-888-312-2221 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website https://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

Independent Medical Review (IMR)

If your grievance involves medical necessity, experimental or investigational treatment, or urgent/emergency services, you may be eligible for an IMR through the Department of Managed Health Care. You may request IMR at the same time as an urgent grievance. You are not required to participate in CalOptima Health’s grievance process prior to applying to the Department of Managed Health Care for an IMR. See above for how to contact the Department of Managed Health Care.

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Prior Authorization for Special Medical Services

For some types of care, your doctor or specialist will need to ask your health network or CalOptima Health for permission before you get care, such as prior authorization, prior approval or pre-approval. Care is medically necessary if it is reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or relieve severe pain.

Expedited Review of Coverage Decisions

For a medical condition with symptoms such as illness, severe pain, serious injury, or a medical condition that is quickly getting worse, your doctor or specialist may ask your health network or CalOptima Health for an expedited prior approval or pre-approval.

A request for an expedited review is for a condition below:

A serious risk to your life or that of your unborn child; or
Loss of or serious harm to bodily functions, or
Serious dysfunction of any bodily organ or part.

To request prior authorization, contact your primary care provider (PCP) or specialist.

CalOptima Health or your health network will work with your provider to get all the necessary information to review the request for prior authorization, prior approval or pre-approval. CalOptima Health and your health network use specific guidelines to decide whether a health care service is medically necessary. Call CalOptima Health Customer Service or your health network Customer Service. You have the right to request the criteria used in a decision about your care, at no cost. If you would like a copy of the utilization management processes or a specific treatment guideline or criteria, please call

CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. We have staff who speak your language.

If the request is denied, you will be informed and told how to file a grievance to appeal the denial. If you disagree with the decision, you have the right to file a grievance to appeal. You have the right to request the specific treatment guideline used to review the prior authorization request.

To request prior authorization, contact your primary care provider (PCP) or specialist. For information on prior authorizations, please refer to the “Prior Authorization” section of the Member Handbook. See a list of procedure codes that require prior authorization by your provider below:

2027 Procedure Codes

January–March 2027

Effective January-March 2027 (Physician-Administered Drug Prior Authorization Required List)

Effective January-March (Covered)

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Continuity of Care for New Members by a Non-Contracting Provider

A newly enrolled member who is being treated for one of the conditions listed can ask to continue care in certain situations with a non-contracting provider:

Acute conditions
Serious chronic conditions
Pregnancy, including immediate postpartum care
A terminal illness
Children from birth to 36 months of age
Prior authorization for surgery or another procedure

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Disclaimers

Plan Information

CalOptima Health plans are offered by CalOptima Health and are certified by Covered California, the state's official health benefit exchange. Benefit details, copays, deductibles and out-of-pocket maximums may change. See your Summary of Benefits and Coverage (SBC) and Member Handbook/Evidence of Coverage (EOC) for complete and binding plan details.

Network Providers

CalOptima Health is a health maintenance organization (HMO). Services must be received from in-network providers except in the case of emergency care or when CalOptima Health authorizes out-of-network care. Provider availability may change. Use the Find a Doctor tool at www.caloptima.org to confirm if a network participates in our plans before you get services.

Financial Help

Premium tax credits and cost-sharing reductions are administered by Covered California and the federal government. Eligibility is based on your household income and size at the time you enroll. Enhanced federal subsidies that were in effect through December 31, 2025, have expired. Standard Affordable Care Act (ACA) subsidy rules apply for 2026. Subsidy amounts may change based on federal and state laws.

Prescription Drug Coverage

Covered drugs, Drug Formulary (drug list) tiers and cost-sharing amounts may change. CalOptima Health will notify members of any mid-year Drug Formulary changes that affect covered drugs. See the current Drug Formulary for a complete list of covered medications.

Nondiscrimination

CalOptima Health complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CalOptima Health provides free language assistance services to members whose primary language is not English. To request language assistance, call CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m.

Privacy

CalOptima Health is required by the Health Insurance Portability and Accountability Act (HIPAA) and California state law to maintain the privacy of your protected health information (PHI). See the Notice of Privacy Practices for a full description of how we use and protect your information.

Fraud, Waste and Abuse

CalOptima Health is committed to preventing, detecting, and correcting fraud, waste, and abuse. Members, providers and the public may report concerns confidentially through the Compliance and Ethics Hotline at 1-855 507-1805 (TTY 711) or by completing the Compliance and FWA Reporting Form. Reports may be made anonymously.

Complaints to the Department of Managed Health Care

If you have a complaint about your CalOptima Health plan that has not been resolved through our internal process, you may call the Department of Managed Health Care at 1-888-466-2219 (TDD 1-877-688-9891).

Accessibility

This information is available in other formats for members with disabilities, including large print, audio and electronic formats. To request an accessible format, call CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m.

Need Help?

If you have questions about your rights, need help filing a grievance, complaint, or appeal, or want a document mailed to you, call CalOptima Health Customer Service toll-free at
1-888-312-2221 (TTY 711), Monday-Friday, from 8 a.m. to 6 p.m. We have staff who speak your language.

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Your Rights

Introduction

Rights and Responsibilities

As a CalOptima Health plan member, you have rights and responsibilities. Understanding both helps you get the best care possible and keeps your coverage running smoothly.

As a Member, You Have a Right to:

Receive information about your rights and responsibilities.
Receive information about your plan, the services your plan offers you, and the health care providers available to care for you.
Make recommendations regarding the plan’s member rights and responsibilities policy.
Receive information about all health care services available to you, including a clear explanation of how to obtain them and whether the plan may impose certain limitations on those services.
Know the costs for your care, and whether your deductible or out-of-pocket maximum has been met.
Choose a health care provider in your plan’s network, and change to another doctor in your plan’s network if you are not satisfied.
Receive timely and geographically accessible health care.
Have a timely appointment with a health care provider in your plan’s network, including one with a specialist.
Have an appointment with a health care provider outside of your plan’s network when your plan cannot provide timely access to care with an in-network health care provider.
Certain accommodations for your disability, including
- Equal access to medical services, which includes accessible examination rooms and medical equipment at a health care provider’s office or facility.
- Full and equal access, as other members of the public, to medical facilities.
- Extra time for visits if you need it.
- Taking your service animal into exam rooms with you.
Purchase health insurance or determine Medi-Cal eligibility through the California Health Benefit Exchange, Covered California.
Receive considerate and courteous care and be treated with respect and dignity.
Receive culturally competent care, including but not limited to:
- Trans-inclusive health care, which includes all medically necessary services to treat gender dysphoria or intersex conditions.
- To be addressed by your preferred name and pronoun.
Receive from your health care provider, upon request, all appropriate information regarding your health problem or medical condition, treatment plan, and any proposed appropriate or medically necessary treatment alternatives. This information includes available expected outcomes information, regardless of cost or benefit coverage, so you can make an informed decision before you receive treatment.
Participate with your health care providers in making decisions about your health care, including giving informed consent when you receive treatment. To the extent permitted by law, you also have the right to refuse treatment.
A discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Receive health care coverage even if you have a pre-existing condition.
Receive medically necessary treatment of a mental health or substance use disorder.
Receive certain preventive health services, including many without a co-pay, co-insurance, or deductible.
Have no annual or lifetime dollar limits on basic health care services.
Keep eligible dependent(s) on your plan.
Be notified of an unreasonable rate increase or change, as applicable.
Protection from illegal balance billing by a health care provider.
Request from your plan a second opinion by an appropriately qualified health care provider.
Expect your plan to keep your personal health information private by following its privacy policies, and state and federal laws.
Ask most health care providers for information regarding who has received your personal health information.
Ask your plan or your doctor to contact you only in certain ways or at certain locations.
Have your medical information related to sensitive services protected.
Get a copy of your records and add your own notes. You may ask your doctor or health plan to change information about you in your medical records if it is not correct or complete. Your doctor or health plan may deny your request. If this happens, you may add a statement to your file explaining the information.
Have an interpreter who speaks your language at all points of contact when you receive health care services.
Have an interpreter provided at no cost to you.
Receive written materials in your preferred language where required by law.
Have health information provided in a usable format if you are blind, deaf, or have low vision.
Request continuity of care if your health care provider or medical group leaves your plan or you are a new plan member.
Have an advance health care directive.
Be fully informed about your plan’s grievances procedure and understand how to use it without fear of interruption to your health care.
File a complaint, grievance, or appeal in your preferred language about:
- Your plan or health care provider.
- Any care you receive, or access to care you seek.
- Any covered service or benefit decision that your plan makes.
- Any improper charges or bills for care.
- Any allegations of discrimination on the basis of gender identity or gender expression, or for improper denials, delays, or modifications of trans-inclusive health care, including medically necessary services to treat gender dysphoria or intersex conditions.
- Not meeting your language needs.
Know why your plan denies a service or treatment.
Contact the Department of Managed Health Care if you are having difficulty accessing health care services or have questions about your plan.
To ask for an Independent Medical Review (IMR) if your plan denied, modified, or delayed a health care service.

As a Plan Member, You Have the Responsibility to:

Treat all health care providers, health care provider staff, and plan staff with respect and dignity.
Share the information needed with your plan and health care providers, to the extent possible, to help you get appropriate care.
Participate in developing mutually agreed-upon treatment goals with your health care providers and follow the treatment plans and instructions to the degree possible.
To the extent possible, keep all scheduled appointments, and call your health care provider if you may be late or need to cancel.
Refrain from submitting false, fraudulent, or misleading claims or information to your plan or health care providers.
Notify your plan if you have any changes to your name, address, or family members covered under your plan.
Timely pay any premiums, copayments, and charges for non-covered services.
Notify your plan as soon as reasonably possible if you are billed inappropriately.

How to File a Grievance

Grievances

You are not satisfied with the service, quality of care or how long it took to get care from your primary care provider (PCP), your PCP’s health network, or other health care providers, such as a hospital or pharmacy.
You are not satisfied with the service or care CalOptima Health gives you.
You believe you have faced discrimination from your PCP, your PCP’s health network, other health care provider, staff, or CalOptima Health.
You are not satisfied with how long it took to get covered benefits, including getting an appointment, or time in a waiting room or in the exam room.
You received a written denial, delay or modification of a service or a drug that requires prior authorization.
You received a written denial for a second opinion, or we did not respond to your request for a second opinion quickly, as appropriate for your condition.
You were told that the services are not a covered benefit, and you believe the services should be covered.
You want us to continue to cover an ongoing course of covered treatment.
We cancelled, terminated, rescinded or did not renew your membership and you disagree with that decision.
We declined your application for coverage, and you disagree with that decision.

How to File a Grievance

Write, visit or call CalOptima Health. You may also file a grievance online in English or in Spanish through CalOptima Health’s website at www.caloptima.org.
Call CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, 8 a.m.to 6 p.m. We have staff who speak your language.
Please contact CalOptima Health as listed below if you need a grievance form in a language other than Spanish or English, or in another format (such as large print or audio).

CalOptima Health
Customer Service
505 City Parkway West
Orange, CA 92868

1-888-312-2221 (TTY 711 if you are deaf or hard of hearing)

Urgent Grievances

Severe pain
Potential loss of life, limb, or major bodily function
Serious jeopardy to your life, health, or ability to attain, maintain, or regain maximum function

Want Someone to Represent You?

If you want someone other than your doctor to represent you in an appeal or grievance, complete the Authorized Assistant form and include it with your submission.

Mail grievances, including appeals to:

CalOptima Health
Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868

Fax Number: 1-714-246-8562

Quality of Care Complaints

Department of Managed Health Care Complaint Process

Independent Medical Review (IMR)

Prior Authorization for Special Medical Services

Expedited Review of Coverage Decisions

A request for an expedited review is for a condition below:

A serious risk to your life or that of your unborn child; or
Loss of or serious harm to bodily functions, or
Serious dysfunction of any bodily organ or part.

To request prior authorization, contact your primary care provider (PCP) or specialist.

CalOptima Health Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. We have staff who speak your language.

2027 Procedure Codes

January–March 2027

Effective January-March 2027 (Physician-Administered Drug Prior Authorization Required List)