Grievance, Appeals, and State Hearings

How to File a Complaint or Appeal

There are two types of grievances; complaint and an appeal. You have the right to file a complaint or an appeal on any issue that is regarding your Medi-Cal benefit. Your grievance must explain your issue and why you disagree with a decision made by PHC, one of its providers, or if you are not happy with the service you received. Please note that PHC does not handle issues about your Medi-Cal eligibility. For eligibility issues contact your County Eligibility Worker.​

Grievance Process

If you want to file a complaint or if you disagree with a decision made by PHC or a provider, you may file a grievance.

Filing a Grievance

Members or a member's authorized representative may file a grievance by using one of the five methods listed below:

1.  By Telephone: You may file a grievance or ask questions about the grievance process by calling the PHC Member Services Department at 1-800-863-4155. Bilingual staff is available and PHC uses an interpreter service for members who speak other languages.

2.  In Writing: You may file a grievance in writing to PHC. Written grievances should be sent to:

Southern Counties (Lake, Marin, Mendocino, Napa, Solano, Sonoma, Yolo)

Partnership HealthPlan of California 
4665 Business Center Drive
Fairfield, CA 94534
Attention: Grievance Unit

Northern Counties (Del Norte, Humboldt, Lassen, Modoc, Shasta, Siskiyou, Trinity)

PHC: Redding Regional Office
3688 Avtech Parkway
Redding, CA 96002

Attention: Grievance Unit

3.  In Person: You may file your grievance in person by visiting PHC's office at: 

Southern Counties (Lake, Marin, Mendocino, Napa, Solano, Sonoma, Yolo)

Partnership HealthPlan of California 
4665 Business Center Drive
Fairfield, CA 94534

Northern Counties (Del Norte, Humboldt, Lassen, Modoc, Shasta, Siskiyou, Trinity)

PHC: Redding Regional Office
3688 Avtech Parkway
Redding, CA 96002

Members can receive assistance in filing a complaint or an appeal from the grievance staff or a Member Service Representative. If the member is under the age of 18, a parent or guardian may file a complaint on his or her behalf. Members may also fill out an Authorized Representative Form to authorize someone of their choice to represent them.

4.  Contracted Provider: You may file your grievance at the office of any provider that is contracted with PHC. Forms titled "Request for a Complaint or Appeal" may be used to file your grievance. These forms are located at all provider offices that are contracted with PHC.

5.  Website: Members can file a complaint or appeal by going to PHC's website by clicking here and select "Online Grievance Form".

Processing your Grievance

Within five (5) calendar days of receipt of your request for a grievance, the PHC grievance unit will send you an acknowledgement letter saying we received your grievance. The letter will also give you the name, address and phone number of the PHC grievance staff that will be handling your grievance and the date your grievance was received. Along with that letter, the grievance staff will also send you information (this form) that describes the grievance process, outlines your rights in the grievance process, provides information about the State Hearing process and also provides addresses and phone numbers of local Northern California Legal Aid offices.

The grievance staff will work hard to get more information which may help us decide on a better resolution of your grievance. If necessary, the PHC grievance staff may contact you if she/he has any questions about your grievance or if more information is needed.

You can contact the PHC grievance staff to discuss your grievance.

Within thirty (30) calendar days from the date of receipt of the grievance, the PHC grievance staff will mail a written letter that outlines PHCs resolution to your grievance.

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) 863-4155 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. 

Expedited Review of Your Grievance

​If you feel that a delay in processing your grievance through the standard timeframe would create a serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, you can call PHC's Member Service Department at 800-863-4155 and request an expedited grievance.​

Your Rights in the Grievance Process

As a member of the Partnership HealthPlan of California (PHC), you have the following rights in filing a grievance with PHC:

  1. You will receive written acknowledgement of your grievance request within five (5) calendar days from the date your grievance was received. The acknowledgement letter will let you know the day that PHC received your grievance request and the name, address and phone number of the PHC grievance staff that will be handling your grievance.
  2. You will receive a written response/resolution to your grievance within thirty (30) calendar days of the date it was received by PHC.
  3. The written response/resolution to your grievance will summarize your grievance and PHC's proposed resolution.
  4. If you do not speak English fluently, you have the right to request translation services so that you are able to fully communicate with grievance staff in providing more information or discussing a solution to your grievance.
  5. You have the right to propose a resolution to the grievance.
  6. You have the right to obtain representation by an advocate or legal counsel to assist you in filing and/or resolving your grievance. You may obtain information about legal counsel from several sources, including Legal Services of Northern California (LSNC). Refer to the Legal Services of Northern California section of this information, for a list of locations and phone numbers of offices located within PHC's designated counties.
  7. You may request an expedited review of your grievance. PHC will grant your request for an expedited review, if PHC medical staff determines that it involves an imminent and serious threat to your health, including, but not limited to potential loss of life, limb, or major bodily function. In the case of expedited review of grievances, PHC makes a decision and notifies you as expeditiously as the medical condition requires, but no later than 72 hours from the date the expedited review was requested.
  8. You must file a grievance through PHC. Once you have exhausted your Appeal rights, you have the right to file a request for a State Hearing with the California Department of Social Services within one-hundred-twenty (120) calendar days following the date of the resolution that caused you to be dissatisfied. Refer to your Member Handbook Section 5 for more information about filing a State Hearing through the State Department of Social Services' State Hearing Division.
State Hearing Information - For members covered by Medi-Cal who have exhausted their appeal rights

There are four ways to request a State Hearing:

  1. BY TELEPHONE: You can call the State at (800) 952-5253.
    • Hearing impaired members may use TDD by calling (800) 952-8349.
  2. BY MAIL:You can send a Hearing Request form or your own written request for a State Hearing to:

    California State Department of Social Services
    State Hearing Division
    P.O. Box 944243, Mail Station 9-17-37
    Sacramento, CA 94244-2430

  3. BY FAX: You can fax your request to the State at (916) 651-5210 or (916) 651-2789.
  4. IN PERSON: You can turn in a Hearing Request form or your own written request at one of the local County offices
Legal Services of Northern California

Legal Services of Northern California (LSNC) may provide legal assistance with grievance cases or State Hearings. For information about the services that are offered through LSNC, please call (888) 354-4474.

Request for an Appeal or Complaint Form

Click here to get a Request for an Appeal or Complaint Form

Click here to file a Civil Rights Complaint

Online Grievance Form

Click here for the Medi-Cal online Grievance form

Click here for the Healthy Kids online Grievance form