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, 490 KB)| 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 |
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:
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.
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.
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
For mental health and substance disorder services, call (877) 263-9952.
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: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.
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.
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].
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.
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:
(800) 927-HELP (4357) [TTY: (800) 482-4833)] 8 a.m. to 5 p.m., Monday through Friday (excluding holidays)
California Department of Insurance, Health Claims Bureau
300 S. Spring St., South Tower
Los Angeles, CA 90013