Your Rights

Rights and Responsibilities

As a member of CalOptima Health, you have certain rights and responsibilities.

You have the right to:

• Be treated with respect and dignity by all CalOptima Health, health network and provider staff
• Privacy and to have your medical information kept confidential
• Get information about CalOptima Health, our health networks, our providers, the services they provide, and your member rights and responsibilities
• Choose a primary care provider (PCP) within CalOptima Health's network
• Talk openly with your health care providers about medically necessary treatment options, regardless of cost or benefit
• Help make decisions about your health care, including the right to say “no” to medical treatment
• Voice complaints or appeals, either verbally or in writing, about CalOptima Health or the care we provide
• Get oral interpretation services in the language that you understand
• Make an advance directive
• Access family planning services, Federally Qualified Health Centers, Indian Health Service Facilities, sexually transmitted disease services and emergency services outside CalOptima Health's network
• Ask for a State Hearing, including information on the conditions under which your State Hearing can be expedited
• Have access to your medical record, and where legally appropriate, get copies of, update or correct your medical record
• Access minor consent services
• Get written member information at no cost in braille, large-size print and other formats upon request and in a timely manner appropriate for the format being requested
• Be free from any form of control or limitation used as a means of pressure, punishment, convenience or revenge
• Get information about your medical condition and treatment plan options in a way that is easy to understand
• Make suggestions to CalOptima Health about your member rights and responsibilities
• Freely use these rights without negatively affecting how you are treated by CalOptima Health, providers or the state

Your responsibilities

• Knowing, understanding and following your member handbook
• Understanding your medical needs and working with your health care providers to create your treatment plan
• Following the treatment plan you agreed to with your health care providers
• Telling CalOptima Health and your health care providers what we need to know about your medical condition so we can provide care
• Making and keeping medical appointments and telling the office when you must cancel your appointment
• Learning about your medical condition and what keeps you healthy
• Taking part in health care programs that keep you healthy
• Working with and being polite to the people who are partners in your health care
   

Compliance and Ethics Hotline 1-855-507-1805 (TTY 711)

Call Us

If you see any activity that you think is fraud or waste, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). You can also report the activity using CalOptima Health’s Compliance and Fraud, Waste and Abuse (FWA) Reporting form.

You do not have to give your name to report fraudulent activity.

Compliance and Fraud Waste, and Abuse Reporting Form
 

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 Health or a provider:

A complaint or grievance is when you have a problem with your health network, CalOptima Health 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 Health’s decision not to cover or change your services.

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

• Call CalOptima Health Customer Service toll-free at 1-888-587-8088 (TTY 711), Monday through Friday, from 8 a.m. to 5:30 p.m. We have staff who speak your language. 
• 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 Health and mail it to us at the address above

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 Health 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