California California Managed Care Members Grievance Form Download Printable PDF

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.”

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 #

________________________________________________________________________________

Date of Birth

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

Name: __________________________________ Daytime Telephone #

________________________

Relationship to Member:

________________________________________________________________

Address: __________________________________________________________________

City: ____________________________ State: _________ Zip: ______________________

Write what your grievance is about. Give dates, times, people’s names, places, etc. that are

involved.

______________________________________________________________________________

Revised 06/09

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.”

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 #

________________________________________________________________________________

Date of Birth

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

Name: __________________________________ Daytime Telephone #

________________________

Relationship to Member:

________________________________________________________________

Address: __________________________________________________________________

City: ____________________________ State: _________ Zip: ______________________

Write what your grievance is about. Give dates, times, people’s names, places, etc. that are

involved.

______________________________________________________________________________

Revised 06/09

Please attach copies of anything that may help us understand your grievance.

If you attach

other pages, please check this box.

Please sign and MAIL or FAX, if applicable, TO your health plan. Please refer to your Evidence of

Coverage for Health Plan contact details.

Date___________ Member Signature: _________________________________________

Date __________ Signature of Representative

_________________________________________

The California Department of Managed Health

NOTICE TO THE MEMBER OR YOUR REPRESENTATIVE:

Care (DMHC) oversees health care plans. If you do not agree with your health plan, you should file a

grievance with your health plan before calling the DMHC. You can still take other action that may be

available to you. If you need help with a grievance in an emergency, or your plan has not given you

an answer on your grievance for more than thirty (30) days, you may call the DMHC for help. You

may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, it

means that someone outside of your health plan will look at a medical decision made about your

care. They will look at whether the care or service is needed. These decisions may be about care or

service asked for by your doctor. They also may be about whether your health plan should pay for

special treatments, or who should pay for emergency health services you get. You may call DMHC

free of charge at 1-888 466–2219. If you have problems with your hearing or speech, you may call

the

TDD

line

1-877-688-9891.

The

DMHC

has

Internet

Web

site

(http:

//www.hmohelp.ca.gov). The Web site also has this form and information on how to use it.

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.

Revised 06/09

"California Managed Care Members Grievance Form" - California

Download "California Managed Care Members Grievance Form" - California

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