File a grievance (complaint)
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, 490 KB)
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. |
---|---|
By mail | Download the Grievance form (PDF, 490 KB) 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, 42 KB)
- For Blue Shield of California Life & Health Insurance Company (Blue Shield Life) plans (PDF, 41 KB)
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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.
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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.
For Blue Shield of California Life & Health Insurance Company (Blue Shield Life) plans, call the California Department of Insurance (CDI) at (800) 927-HELP (4357) [TTY: (800) 482-4833].
Department of Managed Health Care
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 (800) 393-6130 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 topCalifornia 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 phone:
(800) 927-HELP (4357) [TTY: (800) 482-4833)] 8 a.m. to 5 p.m., Monday through Friday (excluding holidays)
By writing to:
California Department of Insurance, Health Claims Bureau
300 S. Spring St., South Tower
Los Angeles, CA 90013
Additional resources
For Blue Shield Promise Medi-Cal members
Filing a grievance or appeal
Online Grievance form
For Promise Cal MediConnect members
Online Grievance form
For Medicare-eligible members
Appeals and grievances
How long does it take to review my case?
All standard grievances are resolved within 30 calendar days.
Expedited (fast) appeals are resolved within 3 calendar days.
How do I get my case reviewed faster? Will calling help?
Unless you have requested an expedited (fast) review, calling will not speed up the process. We can only do expedited (fast) reviews when there is an imminent and serious threat to the health of the member. This includes severe pain and potential loss of life.
If you have more information to provide for your case, we encourage you to call.
Who reviews my request? What is the process?
First, an intake coordinator looks over the case and assigns it to a grievance coordinator (GC). When a case is non-clinical (not related to medical treatment), it is reviewed by the GC.
When a case is clinical (has to do with medical treatment), it is reviewed by a nurse and/or doctor. Sometimes we have to send the case out for specialty review.
What are the most common reasons for a denial?
The most common reasons for denial are: using a service or requesting an item that is not covered by the plan, and having a treatment that is not deemed necessary or is not approved.
What if my case is denied? What are my rights?
We want to be sure that you know your rights. If you are denied, your decision letter will have information about what you can do next depending on your plan, such as apply for an Independent Medical Review.
Can someone file an appeal or a grievance for me?
You may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as your representative to file an appeal or file a grievance on your behalf. Please use the form below to appoint a representative to act on your behalf. Appointment of Representative form (PDF, 161 KB)
For other forms you may use to exercise your privacy rights, please click here: Privacy Forms
Can you email or call me instead of sending letters?
That depends on your specific situation. In some cases, we are required by law to send certain communications by mail. Whenever possible, we will honor your communication preferences.
How do I withdraw my appeal or grievance request?
If you would like to withdraw your appeal or grievance request, you can call the coordinator assigned to your case and let them know. Please see our letter for their name and phone number. Alternatively, you can let the Grievance Department know by calling (844) 831-4133 (TTY: 711), and they will tell your case coordinator.
There are organizations noted in your materials. Who are they and what do they do?
We work with many organizations that oversee health care. Many of them have rules to be sure that the appeals and grievances process is fair. To learn more about them, please visit their websites.
Language assistance
No cost language service. You can get documents read to you and some sent to you in your language.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния
(Department of Insurance), по телефону 1-800-927-4357. Russian
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo Hiểm California tại số 1-800-927-4357. Vietnamese
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Անվճար Լեզվական Ծառայություններ։ Դուք կարող եք թարգման ձեռք բերել և փաստաթղթերը ընթերցել տալ ձեզ համար հայերեն լեզվով։ Օգնության համար մեզ զանգահարեք ձեր ինքնության (ID) տոմսի վրա նշված կամ 1-866-346-7198 համարով։ Լրացուցիչ օգնության համար 1-800-927-4357 համարով զանգահարեք Կալիֆորնիայի Ապահովագրության Բաժանմունք։ Armenian
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
無料の言語サービス 日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、IDカー ド記載の番号または1-866-346-7198までお問い合わせください。更なるお問い合わせは、カリフォルニア州保険庁、1-800-927-4357までご連絡ください。Japanese
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de CA al 1-800-927-4357. Spanish
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
免費語言服務。您可獲得口譯員服務。可以用中文把文件唸給您聽,有些文件有中文的版本,也可以把這些文 件寄給您。欲取得協助,請致電您的保險卡所列的電話號碼,或撥打 1-866-346-7198 與我們聯絡。欲取得其他協助,請致電 1-800-927-4357 與加州保險部聯絡。Chinese
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
무료 통역 서비스. 귀하는 한국어 통역 서비스를 받으실 수 있으며 한국어로 서류를 낭독해주는 서비스를 받으실 수
있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와있는 안내 전화: 1-866-346-7198번으로 문의해 주십시오. 보다 자세한
사항을 문의하실 분은 캘리포니아 주 보험국, 안내 전화 1-800-927-4357번으로 연락해 주십시오. Korean
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357 Tagalog
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
บริการทางภาษาอย่างไม่เสียค่าใช้จ่าย คุณสามารถรับบริการจากล่าม รวมถึงให้เจ้าหน้าที่อ่านเอกสารให้คุณฟัง
หรือส่งเอกสารบางส่วนในภาษาของคุณไปหาคุณได้ หากต้องการความช่วยเหลือ
กรุณาโทรศัพท์ตามหมายเลขที่ระบุอยู่ด้านหลังบัตรประจําตัวของคุณ หรือ ที่หมายเลข 1-866-346-7198
หากต้องการความช่วยเหลือเพิ่มเติม โปรดโทรมาที่ กรมการประกันภัยแห่งมลรัฐแคลิฟอร ์เนียที่หมายเลข 1-800-927-4357 Thai
Language assistance
Blue Shield provides document and telephone support in a variety of languages, so that getting services is easier.
You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help all the CA Department of Insurance at 1-800-927-4357.
© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.