Consumer Assistance at the Department of Health Care Services

Consumer Assistance for Medi-Cal

The information on this page was reported by DHCS to CDII about three of its consumer assistance centers and State Fair Hearings on Medi-Cal.

• State Fair Hearings conducted by the California Department of Social Services (CDSS) are an avenue for Medi-Cal members and applicants to appeal Medi-Cal program decisions.
• Some consumer resources for Medi-Cal and other DHCS programs are not represented below. For example, Medi-Cal applicants and current beneficiaries can get help from their local county office for many coverage issues. Many Medi-Cal members also can get help from their health plan or the Department of Managed Health Care for health care service delivery issues.
• Find additional Tips about How to File a Complaint for Medi-Cal.

DHCS Service Centers

Medi-Cal Office of the Ombudsman

This consumer assistance center provides guidance to Medi-Cal members who have a problem with a managed care plan or with the mental health care delivery system.

• Main line: 1-888-452-8609
• TTY/TDD: California Relay Service (711)
• Hours of operation: Monday-Friday, 8:00 a.m. – 5:00 p.m. (except on state holidays)
• Website: www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx

Medi-Cal Telephone Service Center

This service center assists Medi-Cal members and Medi-Cal providers with fee-for-service billing issues and claims.

• Main line: 1-800-541-5555
• TTY/TDD: 1-866-784-2595
• Hours of operation: Monday-Friday, 8:00 a.m. – 5:00 p.m. (except on state holidays)

Medi-Cal Dental Telephone Service Center

This consumer assistance center helps Medi-Cal members with their dental benefits.

• Main line: 1-800-322-6384
• TTY: 1-800-735-2922
• Hours of operation: Monday-Friday, 8:00 a.m. – 5:00 p.m. (except on state holidays). Some automated services are available through the phone system 7 days a week, 24 hours a day. Voicemail is checked daily.
• Website: dental.dhcs.ca.gov

Medi-Cal Rx Customer Service Center

This service center helps Medi-Cal members with their pharmacy benefits.

• Main line: 1-800-977-2273
• TTY: 1-800-977-2273
• Hours of operation: All seven days a week, all 24 hours
• Website: medi-calrx.dhcs.ca.gov

Complaint Data Highlights

​The below highlights were based on data DHCS reported about consumer inquiries and State Fair Hearings in 2022.

Consumer assistance volume

2,028,588 requests for assistance, including State Fair Hearings and inquiries made to the Office of the Ombudsman, Medi-Cal Telephone Service Center, Medi-Cal Dental Telephone Service Center, and Medi-Cal Rx Customer Service Center

Complaint volume

4,217 (State Fair Hearings on Medi-Cal conducted by CDSS)

Complaint review time

41 days on average, with complaint review times ranging from 1-1,205days

• The above statistics include re-opened cases with durations counted from the time of the first hearing request filing.
• Most State Fair Hearings must be conducted no later than 90 days from the date the hearing request was filed.
• There is a faster hearing process for certain cases involving consumers with urgent clinical issues.

Top reasons for complaints

Reasons for hearings for Medi-Cal Managed Care, Fee-for-Service, Dental, Pharmacy, and other delivery systems

1. Scope of Benefits (34% of complaints)
2. Medical Necessity Denial (21%)
3. Pharmacy Benefits (10%)
4. Dis/Enrollment (10%)
5. Claim Denial (7%)
6. Billing/Reimbursement Issue (5%)
7. Denied Services (5%)
8. Quality of Care (4%)
9. Utilization Review (2%)
10. State Specific (Other)(1%)

Top results of the complaint review

1. Upheld/Health Plan Position Substantiated (49% of complaints)
2. Complaint Withdrawn (32%)
3. No Action Requested/Required (9%)
4. Health Plan Position Overturned (9%)

Note: DHCS reported that many of the Complaint Withdrawn results were for complaints that were resolved before a State Fair Hearing took place.