California Managed Care Members Grievance Form - California

This "California Managed Care Members Grievance Form" is a document issued by the California Department of Managed Health Care specifically for California residents with its latest version released on June 1, 2009.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the California Department of Managed Health Care.

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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
at
1-877-688-9891.
The
DMHC
has
an
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

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