Reporting and Solving Problems

We want to hear your concerns about the health care services you get

There are two kinds of problems that you may have with your health network, CalOptima or a provider:

  • A complaint or grievance is when you have a problem with your health network, CalOptima or a provider, or with the health care or treatment you got from a provider
  • An appeal is when you do not agree with your health network or CalOptima’s decision not to cover or change your services

You should always contact CalOptima first to let us know about your problem. Below are some ways to let us know your concern:

  • Call our Customer Service department
  • Fill out the member grievance or appeal form online and click the “submit” button
  • Visit our office at 505 City Parkway West, Orange, CA 92868
  • Fill out the member complaint form or write a letter to CalOptima and mail it to us at the address above

Instructions for completing the form are here .  

Instructions for completing the form are here .  

After CalOptima Health receives your complaint, we will send you a letter within 5 calendar days letting you know the status of your complaint and the name of our Resolution Specialist you can call if you have questions.

When the form is submitted online after business hours, the notice will be sent to you no later than 5 calendar days from the next business day. The letter explains a response to your complaint will be mailed to you within 30 calendar days of when we get it. For more details, please read the Medi-Cal member handbook.

Urgent or expedited matters: Any complaint with serious health concerns will be reviewed by CalOptima Health within 72 hours of getting the complaint.

You may also call the CalOptima Health Fraud Hotline at 1-855-507-1805 to report any action you think may be fraud. You do not have to give your name to report fraud activity. Fraud is when a doctor or pharmacy asks you to pay more than proper for an office visit or medicines. Fraud is also when someone uses another person’s Medi-Cal card.

CalOptima Health will not discriminate against you or limit your benefits in any way if you express concerns, file a complaint or report fraud.

Notice of your right to a Medi-Cal State Hearing:

A Medi-Cal State Hearing is a meeting with people from the California Department of Social Services (DSS). A judge will help to resolve your problem. You can ask for a State Hearing only if you have already filed an appeal with CalOptima and you are still not happy with the decision. Or, if you have not received a decision on your appeal after 30 days. You must ask for a State Hearing within 120 days from the date on the notice telling you of the appeal decision. Call the DSS Public Response Unit toll-free at 1-800-952-5253. TDD/TTY users can call toll-free at 1-800-952-8349.

Or, you may fill out the form we provided with your appeal resolution notice and mail it to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 09-17-37
Sacramento, CA 94244-2430

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