How to complain or appeal when Medi-Cal mental health or addiction care is denied

This page is general information, not legal or medical advice. Do Not Lose Hope is not a law office, a clinic or a crisis line. If you are in crisis right now, call or text 988. In a life threatening situation, call 911.

A denial feels like a door closing right when you need help most. It is not the end. Medi-Cal gives you the right to ask for a second look, and many people do it without a lawyer. You can also ask someone you trust to do it for you.

What counts as a denial I can appeal?

Medi-Cal calls these decisions an "adverse benefit determination." You can appeal when your county mental health or addiction plan:

• Says no to a service you or your provider asked for
• Approves less than you asked for, or changes it
• Cuts back, pauses or ends care you already get
• Refuses to pay for a service
• Takes too long to approve a service
• Does not give you an appointment in time
• Takes too long to answer your complaint or appeal

The county must send you a letter called a Notice of Adverse Benefit Determination (NOABD). It explains what was decided and your rights. If care is going to be cut or stopped, the county has to send it at least 10 days before.

Did the county miss a deadline, or never send you a letter at all? You may be able to go straight to a State Hearing. See What if the county says no again?

How do I file an appeal?

1. Find the date on your letter. You have 60 days from that date to appeal.
2. Decide who will file. You can file yourself. A relative, friend, advocate, provider or lawyer can also act for you. In Santa Clara County, your provider can file for you with your written OK.
3. Ask for the appeal. Call your county, or send an appeal form or a letter. Some counties also take email or fax.
4. Follow a phone appeal with a written one. The state's rights notice says to send a signed written appeal after you call. Some county pages say a phone call alone is enough. Sending both is the safe choice.
5. Say what you want. Write in plain words what was denied and why you need it. "My counselor says I still need weekly therapy. Please keep it going" is enough.
6. Add proof if you have it. A short note from your counselor, doctor or program helps a lot. Copies, not originals.
7. Keep a copy. Write down the date, who you talked to and what they said.

The county must let you know it got your appeal within 5 days. A different provider from the one who made the first decision will review it. The county then has 30 days to decide and send you a Notice of Appeal Resolution.

You do not need to pay anything. The county must help you fill out forms, and interpreters are free. Just ask.

Example (made up, to show the dates): Ana's county sends a letter dated March 2, 2027 saying her weekly therapy will stop. She calls the county on March 8 and says, "I want to appeal, and I want to keep getting my services while I appeal." That is inside the 10 day window, so she can ask to keep her therapy going during the appeal. She mails a signed letter the same day and keeps a copy. Her last day to appeal would have been May 1, 2027 (60 days from the letter date). The county must decide within 30 days. If it says no, she has 120 days from the date on that decision to ask for a State Hearing.

How do I keep my care while I appeal?

If the county is cutting back, pausing or ending care you already get, you can ask to keep it during the appeal. This is called Aid Paid Pending.

• Ask within 10 days of the date on the letter, or before the date your care is set to stop, whichever is later.
• Say clearly: "I want to keep getting my services while I appeal."
• If you lose the appeal, the state notice says you will not have to pay for the care you got while you waited.

Missed the 10 days? You can still appeal within 60 days. Your care just may stop while you wait.

What if I cannot wait 30 days?

Ask for an expedited (fast) appeal. If waiting 30 days could seriously harm your life, health or ability to function, the county must decide within 72 hours. When you call or write, say "This is urgent," and explain why. A note from your provider helps.

If the county says no to a fast appeal, it must tell you in writing within 2 days. Your appeal then goes on the normal 30 day track, and you can file a complaint about that decision.

What if the county says no again?

You can ask for a State Hearing. A judge who does not work for the county will look at your case. It is free.

• Ask within 120 days from the date on the Notice of Appeal Resolution.
• No answer to your appeal after 30 days? You can ask for a hearing then. If the county did not follow the rules on letters or deadlines, the state treats your appeal as done, and you can move on to a hearing.
• To keep your care going during the hearing, ask within 10 days of the date the appeal decision was mailed or handed to you, and say you want your services to continue.

How to ask for a State Hearing:

• Online: California Department of Social Services hearing request
• Phone: (800) 743-8525. The state notice also lists 1-800-952-5253, TTY 1-800-952-8349.
• Mail: California Department of Social Services, State Hearings Division, P.O. Box 944243, Sacramento, CA 94244-2430. Use the Mail Station number printed on your own notice.

Include your name, address, phone, date of birth and the reason you want a hearing. If someone is helping you, add their name and contact. Tell them your language so an interpreter is ready. For the hearing, you must tell the hearing office that your helper may speak for you.

How long it takes: a standard hearing decision can take up to 90 days. If waiting could seriously harm your life, health or ability to function, ask for an expedited hearing and send a letter from you, your provider or the plan that explains why. Fast decisions come within 3 working days.

What if my problem is not a denial?

That is a grievance, which is another word for a complaint. You can file one about anything else in your care, at any time. Some examples:

• Staff were rude or did not respect you
• You could not get an interpreter
• You did not get the help you were promised
• You worry about your privacy

You can file in person, by phone, by mail, by fax or by email. The county must let you know it got your complaint within 5 days and answer within 30 days. Filing cannot be held against you. You will not lose services for speaking up.

Waited too long for an appointment? That may count as a denial you can appeal, not just a complaint. Ask the county to send you a written notice.

Can I get a second opinion?

Yes. The state notice says you can ask for a second opinion from a qualified health professional, inside or outside the plan's network, at no extra cost. Ask the same office where you file appeals.

Who can help me for free?

These offices and groups handle Medi-Cal complaints and appeals. Contact them to confirm hours, languages and openings. Being listed here is not a referral or a promise of service.

• Health Consumer Alliance: free phone or in person help for Californians who have trouble getting or keeping health coverage. 888-804-3536, TTY 877-735-2929. healthconsumer.org
• San Mateo County Office of Consumer and Family Affairs (BHRS): helps clients and families file grievances and resolve concerns about their rights. (800) 388-5189, OCFA@smcgov.org. Support for Clients and Family
• Santa Clara County Member Rights Unit (Behavioral Health Services): grievances, appeals and help writing them. (800) 704-0900 or (408) 793-5894. P.O. Box 28504, San Jose, CA 95159-9903. Concerns and complaints
• DHCS Office of the Ombudsman: a neutral office that helps settle problems between Medi-Cal members and plans, and helps people reach county mental health services. (888) 452-8609. Office of the Ombudsman
• DMHC Help Center: for problems with a Medi-Cal health plan. 1-888-466-2219. File a complaint
• Need care while you sort this out? See Mental health care without fear or How to find drug and alcohol treatment for an adult.

What mistakes should I avoid?

• Waiting to see what happens. The 10 day window to keep your care is short. Act the day you get the letter.
• Throwing away the envelope or letter. The dates on them start your clocks.
• Only calling. Follow up in writing and keep a copy.
• Stopping treatment on your own. If your care is approved to continue, keep going to appointments.
• Going it alone if you feel worn down. A family member, advocate or provider can file for you.

Questions people ask

Will appealing make the county angry or cut me off? No. The law protects you from being treated differently for filing a complaint or appeal.

Does this affect my immigration case? Appealing a Medi-Cal decision is about your health care. If you have questions about benefits and immigration, see Will using benefits like CalFresh hurt my immigration case? and talk to a trusted immigration lawyer.

I lost my letter. Can I still appeal? Yes, call the county office above and ask for a copy and the date it was sent. Do it quickly so you stay inside the 60 days.

My teen's care was cut. Can I appeal for them? Yes. A parent or caregiver can act for a young person. See also Where your child can get mental health help.

I am in a drug or alcohol program. Do the same rules apply? Yes. County drug and alcohol treatment under Medi-Cal uses the same appeal and complaint steps. See also Your rights in a drug or alcohol treatment program.

Is there a checklist I can print?

You have the right to ask again, and the right to be heard. One letter, one call, can keep your care going. We are with you.