A delay or denial is frustrating, especially when discharge pressure is building. The next step depends on what actually happened. A request for more information is not the same as a denial. An incomplete referral is not the same as a determination that the service is not medically appropriate. Start with the written notice and the plan’s own explanation.
This is general information
Appeal and hearing rights are time-sensitive and case-specific. Follow the instructions on the member’s notice and seek qualified help when needed; this article is not legal advice.
First, name the decision
Ask whether the plan is still reviewing, requesting information, declining to authorize, authorizing a reduced scope or directing the request to another benefit. If the answer is adverse, request the formal notice if it has not arrived.
The notice should explain the reason and the member’s options. Keep the envelope or electronic delivery date. A phone summary can help, but it should not replace the document that contains deadlines and rights.
Match the response to the stated reason
If information is missing, provide the requested item through the approved secure channel and confirm receipt. If the plan believes the member does not meet a criterion, compare the explanation with the current policy and the member’s records. If the proposed setting is the issue, ask whether a different provider or service plan would address the concern.
Avoid sending a larger, unfocused packet. A concise response that directly addresses the stated gap is easier to review than hundreds of pages without a roadmap.
Use the plan’s grievance and appeal process
DHCS policy preserves a member’s right to file a grievance or appeal when a Community Support offered by the plan is not authorized because of an adverse service determination. The notice should explain how, where and when to act.
Ask member services for language assistance or an accessible format if needed. The member may also choose an authorized representative. Keep a copy of everything submitted and proof of delivery.
- Decision notice and delivery date
- Member and plan identification
- The exact decision being challenged
- A short explanation tied to supporting records
- Copies of relevant assessments or care notes
- Submission confirmation and follow-up date
Protect safety while review continues
An appeal does not create a safe discharge plan by itself. Ask the hospital or SNF what interim plan is clinically appropriate, what services remain available and who is responsible for follow-up. If the person is at home, involve the treating team when needs cannot be met safely.
Do not move into a setting that has not accepted the resident or cannot meet the current needs simply to solve a deadline.
Turn the outcome into a clearer plan
Whether the decision changes or not, document what the review clarified: level-of-care findings, provider requirements, excluded costs, alternative benefits and remaining choices. That information can improve the next conversation.
If the problem began with an incomplete record, revisit what to gather before a transition review.
Sources & important note
Zeal reviewed the primary sources below while preparing this article. Policies, benefits and individual circumstances can change; confirm current requirements with the responsible agency, health plan and licensed provider.
- DHCS: Community Supports Policy Guide, Volume 1
- DHCS: Community Supports Policy Guide appeal and grievance requirements
- DHCS: Medi-Cal Managed Care Health Plan Directory
Editorially reviewed September 2026.