How do I report my California health plan for failing to provide timely access to a specialist appointment?

To report your California health plan for failing to provide timely access to a specialist, you must first file a formal grievance with the plan itself, and then file a complaint with the appropriate state regulator if the issue is not resolved. Here are the steps to take: Step 1: Document Everything Before you file, gather all your information. Write down your health plan ID number, the name of the specialist you need to see, the date your primary doctor made the referral, and any authorization numbers. Keep a log of every phone call with your health plan, noting the date, time, and name of the representative you spoke with. Step 2: File a Grievance with Your Health Plan You are required to try to resolve the issue with your health plan first. Call the member services phone number on your insurance card and tell them you want to file a formal grievance for failure to provide timely access to care. Your plan must acknowledge your grievance within five business days and send you a written resolution within 30 calendar days. Step 3: Contact the Department of Managed Health Care (DMHC) If your plan does not resolve your grievance within 30 days or denies your request, you should escalate the issue to the DMHC. The DMHC is the state regulator for most California health plans. Call the DMHC Help Center at 1-888-466-2219. They can open a case for you immediately. Step 4: Submit a Formal Complaint You can also file a formal complaint online at the DMHC website (www.dmhc.ca.gov). Use the "File a Complaint/Independent Medical Review" form. Provide all the documentation you gathered in Step 1. The DMHC will investigate and has the authority to order your plan to comply with the law. Important Details and Nuances Under California regulations, your health plan must provide an appointment with a specialist within 15 business days of your request for a non-urgent issue. If your doctor determines your need is urgent, the plan must resolve your grievance within 72 hours, and you can contact the DMHC immediately without waiting 30 days. Warnings and Limitations In most non-urgent cases, you must complete your health plan's internal grievance process before the DMHC will accept your complaint. This process applies to health plans regulated by the DMHC, which includes most HMOs and some PPOs. If your plan is regulated by the California Department of Insurance (CDI), you must file your complaint with them instead. This is general information and does not constitute legal advice. For complex situations, or if you have suffered harm due to the delay, consult with a qualified California attorney.