Table of Contents
What is a grievance?
How to file a grievance
What to expect
Asking for an expedited (fast) appeal
Asking for an Independent Medical Review
Appealing canceled health coverage
Department of Managed Health Care
California Department of Insurance
FAQs

 

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
     
If your grievance doesn’t involve appealing a decision about your coverage, it may be a Potential Quality Issue (PQI). Potential Quality Issues are typically about us or one of our network providers, and involve the quality of care or a service provided to you, including:
 
  • 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
     
When you’re not satisfied with us or one of our network providers, but it doesn’t involve claims or clinical services, your grievance is called a complaint. If your grievance doesn’t fall under the definition of an appeal or PQI, it’s most likely a complaint.

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
Attn: Member Services Grievances
P.O. Box 5588
El Dorado Hills, CA 95762-0011
 

For mental health and substance use disorder services:

Blue Shield of California Mental Health Service Administrator
PO Box 719002
San Diego, CA 92171-9002
 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.
 
 
Back to top

 

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.

Learn more about our grievance process:
 

 

Back to top


 

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 

Blue Shield doesn’t cover experimental or investigational medical services. If you’re denied services because they’re deemed not medically necessary, experimental, or investigational, you may ask for a review by an outside agency.

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.
 
To request an IMR:
 
  • 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.
 
Back to top

 

Appealing canceled health coverage

If you believe your health coverage has been or will be wrongly canceled, you can appeal to the agency in charge of your health plan.

For Blue Shield of California (Blue Shield) plans, you have two options to file with the Department of Managed Health Care (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 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 (888) 466-2219 [TTY: (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 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

Back to top

 

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