Appeal or Grievance Form

Many issues or concerns can be promptly resolved by our Member Services Department. If you have not already done so, you may want to first contact Member Services before submitting one of the forms below.

Health Net of CA encourages you to provide a detailed account of your experience. Your feedback is important to us and we appreciate the time you have taken to share this information.

If you believe a delay in the decision making may impose an imminent and serious threat to your health, please contact customer service at 1-833-959-2907 (TTY 711).

What should I do?

Appeal

File an Appeal when appealing the denial of a service or benefit

Grievance

File a Grievance to formally express your dissatisfaction with care or service(s) you have received

Type of Issue

* = Required

Which would you like to file? * An Appeal A Grievance

Are you filing this for yourself or another person? * Self Child Parent Spouse Other

If Other, please specify:

Information about Member

Member ID *

Member First Name *

Member Last Name *

Mailing Address *

City

State *

Postal/Zip Code *

Telephone number: *

Email address: *

Note: Please tell us how to contact you in case we have questions about your appeal or grievance.

Best way to contact you? * Phone Mail

OK to leave a confidential message? * Yes No

Issue Details

Name of Provider

Date of Service/Occurrence * MM/DD/YYYY

Description of the concern or issue? *

Please include to the best of your ability all relevant dates, names of individuals directly involved, any phone numbers where you made contact or addresses of visits, billed amounts, any specifics on the type of service/provider you are attempting to access any other details that you believe will assist in the investigation or resolution of this matter.

Description of the concern or issue *

A message to State Health Program members, from the Department of Managed Health Care

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 1-833-448-2042 (TTY 711) and use your health plan 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The departments internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.