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Northridge, CA 91325
(818) 654-3400
(866) 654-3471
44469 N. 10th Street W
Lancaster, CA 93534
(661) 945-9411
275 N. El Cielo Road
Palm Springs, CA 92262
(800) 500-5215
(760) 969-6526
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Bakersfield, CA 93309
(661) 327-4411
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San Luis Obispo, CA 93401
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Lancaster, CA 93534
(800) 266-4364
(661) 945-5984
12370 Hesperia Road Ste. 3
Victorville, CA 92395
(760) 245-4747
191 S. Buena Vista St., Suite 200
Burbank, CA 91505-4542
(818) 637-2000
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Orange, CA 92868
(800) 747-2362

California Managed Care Members Grievance Form

Attention Medicare Advantage members – do not complete this form.
Request the “California Medicare Advantage Plan Member Appeal and Grievance Form”

You have the right to file a grievance about any of your medical care or service.  If you want to file a grievance, please use this form.There is a process you need to follow to file a grievance.  Your health plan must, by law, give you an answer within 30 days.  If you have any questions or prefer to file this grievance orally please call your medical group or health plan customer service department at the phone number on your health identification (ID) card.  If you think that waiting for an answer from your health plan will hurt your health, ask for an “Expedited Review.”

For Expedited Review, please check this box.
 
Please print or type the following information:
 
Member Name (Last, first, middle initial)
Address Home Phone Number (include area code)
City, State, Zip Work Phone Number (include area code)
Name of Employer or Group Enrollment or Member ID #
Health Plan Medical Group
Date of Birth Member Email
   

If someone other than the member is filing this grievance, please provide the following information:

   
Name: Daytime Phone Number
Relationship to Member:  
Address:  
City:  State:
Zip:  
 
 
Write what your grievance is about.  Give dates, times, people’s names, places, etc. that are involved.
 
Date Electronic Signature of Member:
Please electronically sign this form by checking this box.
Date Electronic Signature of Representative:
Please electronically sign this form by checking this box.
   
NOTICE TO THE MEMBER OR YOUR REPRESENTATIVE:

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-714-908-5617 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

Federal Employees:  If you are a Federal Employee, you have additional rights through the Office of Personnel Management (OPM) instead of the DMHC. Please reference your Federal Employees Health Benefits (FEHB) Program Brochure, which states that you may ask OPM to review the denial after you ask your health plan to reconsider the initial denial or refusal. OPM will determine if your health plan correctly applied the terms of its contract when it denied your claim or request for service. Send your request for review to: Office of Personnel Management, Office of Insurance Programs Contracts Division IV, P.O. Box 436, Washington, D.C. 20044

Employees of Self-Insured Companies: You may have the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA) if you are enrolled with your health plan through an employer who is subject to ERISA. First, be sure that all required reviews of your claim appeal have been completed and your claim has not been approved. Then consult with your employer's benefit plan administrator to determine if your employer's benefit plan is governed by ERISA. Additionally, you and your health plan may have other voluntary alternative dispute resolution options, such as mediation.