Filing a Grievance
California Health & Wellness wants to fully resolve your problems or concerns. California Health & Wellness will not hold it against you or treat you differently if you file a grievance. A grievance is an expression of dissatisfaction about any matter; such as you are not happy with the services you received or with how you were treated. Grievances are any oral or written complaint submitted to California Health & Wellness that has been initiated by you, or your authorized representative, including your provider, concerning any aspect or action of California Health & Wellness relative to you. An appeal is a request to review an action or adverse determination; such as you requested services and got a denial letter.
How to File a Grievance
Filing a grievance will not affect your healthcare services. We want to know your concerns so we can improve our services.
To file a grievance, call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number). You may file a grievance online at www.CAHealthWellness.com under the secure Member website. You can also write a letter and mail it to the address below or fax your grievance to California Health & Wellness at 1-877-302-3434. Be sure to include:
- Your first and last name.
- Your Medi-Cal ID number.
- Your address and telephone number.
- What you are unhappy with.
- What you would like to have happen.
California Health & Wellness
Grievance and Appeal Coordinator
1740 Creekside Oaks Drive, Suite 200
Sacramento, CA 95833
If someone else is going to file a grievance for you, we must have your written permission for that person to file your grievance or appeal. You can call Member Services to receive a form or go to www.CAHealthWellness.com. This form is to assign your right to file a grievance or appeal to someone else. A doctor acting for you can file a grievance or appeal for you. If you need assistance in completing a grievance or an interpreter, please call California Health & Wellness at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).
If you have any proof or information that supports your grievance, you may send it to us and we will add it to your case. You may supply this information to California Health & Wellness by including it with your online grievance, a letter, or by sending us an email, a fax, or by bringing it to California Health & Wellness in person. You may also request to receive copies of any documentation that California Health & Wellness used to make the decision about your care, grievance, or appeal.
You can expect a resolution orally or a written response from California Health & Wellness within 30 calendar days of your grievance, except in urgent cases which must be resolved, in most cases, within three days.
There will be no retaliation against you or your representative for filing a grievance or appeal with California Health & Wellness.
Department of Managed Health Care (DMHC)
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 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) 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.
Office of the Ombudsman
You can call the Medi-Cal Managed Care Office of the Ombudsman for help with grievances. The Office of the Ombudsman was created to help Medi-Cal beneficiaries fully use their rights and responsibilities as members of a managed care plan. To find out more, call toll-free 1-888-452-8609.