Changing the way you
receive healthcare

  • If You Have a Problem or Complaint

    If you are ever unhappy with the service or care you get from PHC California, you should file a grievance (a complaint) with us. We want you to be satisfied with the plan, our staff and our providers. By filing a grievance, you bring the problem you experienced to our attention so we can take action. You help us become a better health plan.

    A “grievance” is an expression of dissatisfaction about any matter. For example, you would file a grievance if you have a problem like:

    • The quality of your care
    • Waiting times for appointments
    • Waiting time to be seen while in a doctor’s office
    • The way your doctor or his or her staff behave
    • Unable to reach a provider or the managed care plan by phone
    • Inability to receive the information you need
    • Cleanliness or condition of a provider’s office.

    An “adverse benefit determination” is the denial or limit by the plan of services asked for by you or your provider. Examples of an action are:

    • Changing level of service, i.e., outpatient instead of inpatient hospital care
    • Reduction, suspension or termination of a service that was already authorized for you
    • Denial of all or part of the payment for a service or failure to provide the service in a timely manner
    • The health plan’s failure to act on a grievance you requested within 30 days of receiving your request.

    An “appeal” is a request for a review of an adverse benefit determination. For example:

    • If we won’t cover or pay for services you think we should cover, you can file an appeal
    • If we or one of our contracted providers won’t give you a service you think should be covered, you can file an appeal
    • If we or one of our contracted providers cuts back on services you have been getting, you can file an appeal
    • If you think we are stopping your coverage of a service too soon, you can file an appeal

    With your permission, a provider can file a grievance or appeal for you. The health plan is required to keep track of all grievances and appeal so it can report data to the State on a quarterly and annual basis. This information is also used to improve the plan’s service to its members.

    Read how to file a grievance. If you want to appeal an adverse benefit determination we made, read how to make an appeal. You can also read about how to ask for a State Hearing.


    DHCS 030716 PHC FR Form 1.0
    Page Updated: April 4, 2024 @ 8:35pm