Managed Care in California Series, Issue 5: Internal Grievances and External Review for Service Denials in Covered California Plans

Managed Care in California Series, Issue 5: Internal Grievances and External Review for Service Denials in Covered California Plans

Executive Summary

Federal and state law and the Constitution ensure that enrollees in publicly-funded health care plans receive notice, grievance and appeal rights when they are denied access to medical services. Enrollees in Covered California plans have the right to a notice when their plan denies access to a service, and have several avenues to contest the plan’s decision through a grievance or appeal. Frequently, however, enrollees fail to receive the required notice, get an inadequate notice, or do not understand their right to appeal the plan’s decision. This fact sheet will describe the legal protections available to consumers in California and how to enforce these rights.

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