What can I do if Medi-Cal denies my claim?
If Medi-Cal denies coverage for something your child needs, you are entitled to an appeal. An appeal is used when your care plan has taken an Adverse Benefit Determination (ABD), or an action “that affects your care, such as delay, modification, denial, or reduction of services, denial or only partial payment for a service, or the determination that the requested service was not a covered benefit.”
The appeal process changes depending on whether you are enrolled in a managed care plan or fee-for-service (or “straight”) Medi-Cal:
For straight Medi-Cal, the notice of action will typically include information on how to appeal. You can also contact your county office to file a formal complaint and request a Medi-Cal Fair Hearing.
If you’re on a managed care plan, contact your plan’s customer service number. If this does not resolve the problem, you can file an appeal with your care plan. For assistance with this process, you can contact the Medi-Cal Managed Care and Mental Health Office of the Ombudsman.
For more information, check out our article Making the Most of Medi-Cal.