How can we help you?
We’re committed to the highest standards in taking care of you and your health plan needs. However, we know we may not always get everything right. If you’re looking for answers to common questions, or help resolving an issue before filing a grievance, we recommend calling Customer Care at the number on your member ID, or (800) 393-6130.
As a Blue Shield of California member, you have the right to file a grievance if you have any concerns about your coverage or care. If you disagree with a decision we’ve made about your coverage, or aren’t satisfied with the quality of your care, please let us know. We have a fair and transparent process to help resolve the issues you bring to our attention.
If you have an account with us, log in so we can help you quickly fill out the online grievance form. You may also download, fill out, and mail a paper form.
Download the GRIEVANCE FORM (PDF, 1.5MB)
What is a grievance?
A grievance is a formal complaint about your coverage or care.
There are different types of grievances and reasons for filing them. Knowing what they are can help you better understand when to file, how to best address your concerns, and what to expect when waiting for a resolution.
If your grievance is about services or medication your plan covers and how much it will pay for them, it’s an appeal. When you’re not satisfied with a decision we’ve made about your coverage, you may appeal it.
For example, an appeal is a request for reconsideration of decisions concerning:
- Denial of services, benefits, or claims
- Canceled health coverage
- Reduction of benefits or claim payments
- Redirection of services or benefits
- Delays of authorization for services or benefits (access to care)
- Eligibility related denials
- Dissatisfaction with administrative policies
- Dissatisfaction regarding a resolution of a complaint
- Access to care (after services have been provided)
- Referral or authorization procedures
- Communication issues
- Provider or staff behavior
- Coordination of care
- Technical competence or appropriateness
- Facility and office environments
If you find yourself in any of these situations, you can file a grievance using the process outlined below.
How to file a grievance
You may file a grievance up to 180 days from the date on your claim decision, or from the date an incident you’re concerned about occurred.
Most grievances must be filed with Blue Shield of California. Those related to canceled health care may also be filed directly with the Department of Managed Health Care (DMHC). If you’re not satisfied with how a grievance has been resolved, you may ask for an independent review through the DMHC (for Blue Shield plans) or the California Department of Insurance (for Blue Shield Life plans).
File online, by printing and mailing paper forms, or by calling us. Your doctor or someone representing you (usually an attorney, caretaker, or other legally authorized representative) can file an appeal on your behalf by mailing paper forms or by calling.
|Online||Log in / Create account, so we can use your account information to help you fill out the form faster.|
Download the GRIEVANCE FORM (PDF, 1.5MB)
Print the form, fill it out, and send it to:
For medical services:
Blue Shield of California
For mental health and substance use disorder services:
Blue Shield of California Mental Health Service Administrator
|By phone||To file a grievance for medical or pharmacy services by phone,
call the customer care number on your member ID or (800) 393-6130 [TTY 711].
For mental health and substance disorder services, call (877) 263-9952.
What to expect
We’ll mail an acknowledgement letter within 5 calendar days of receiving your grievance.
All standard grievances are resolved within 30 calendar days.
If waiting for a decision puts your health at serious risk, you may ask for an expedited (fast) decision. Expedited appeals are resolved within 3 calendar days.
- For Blue Shield of California (Blue Shield) plans (PDF, 42KB)
- For Blue Shield of California Life & Health Insurance Company (Blue Shield Life) plans (PDF, 41KB)
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Asking for an expedited (fast) appeal
In cases where you or your doctor believe that waiting for a standard decision could seriously harm your health, you may ask for an expedited (fast) appeal. After you make a request, we’ll respond with a decision as soon as possible and within 3 calendar days.
To ask for an expedited appeal in cases involving medical services, call the number on your member ID or write to:
Blue Shield of California
Attn: Customer Service Grievances
P.O. Box 5588
El Dorado Hills, CA 95762-0011
For cases involving mental health and substance abuse disorders, call the Blue Shield Mental Health Service Administrator (MHSA) at (877) 263-9952.Back to top
Asking for an Independent Medical Review
An Independent Medical Review (IMR) is voluntary and offered at no cost to you. However, if you don’t ask for one, you may give up your right to take legal action about the services in question.
- File an appeal with Blue Shield or Blue Shield Life. If you receive a denial, then you may ask for an IMR. Follow the instructions in your denial letter.
- If your appeal is expedited or the service denied is experimental or investigational, you can ask for an IMR right away. Follow the instructions in your acknowledgment letter.
Appealing canceled health coverage
For Blue Shield of California (Blue Shield) plans, you have two options to file with the Department of Managed Health Care (DMHC):
- You may use our standard appeal form and process.
- You may also download the Cancellation of health coverage appeal form, print it out, and mail to the DMHC.
The California Department of Managed Health Care is responsible for regulating healthcare service plans. If you have a grievance against your health plan, you should first call the number displayed in Contact us and shown on your Blue Shield ID card 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 (www.dmhc.ca.gov/) has complaint forms, IMR application forms and instructions online.Back to top
California Department of Insurance
The California Department of Insurance (CDI) is responsible for regulating health insurance plans sold through the Blue Shield of California Life & Health Insurance Company (Blue Shield Life). If you have a grievance against your Blue Shield Life plan, you should first file using Blue Shield’s grievance process.
If you’re not satisfied with how the grievance is resolved, you or your provider may ask for a review through the CDI Health Claims Bureau:
By writing to:
California Department of Insurance, Health Claims Bureau
300 S. Spring St., South Tower
Los Angeles, CA 90013
For Promise Cal MediConnect members
ONLINE GRIEVANCE FORM
For Medicare-eligible members
Appeals and grievances