Grievance or appeal form

I want to report a grievance or appeal

1. Grievance details

Please provide details of the grievance or appeal in the fields below. All fields marked with an asterisk (*) are required.

*Check the one that applies

I am filing a grievance

I am filing an appeal

*Date Date of incident or notice of denial received

*Grievance or appeal description

2. Member information

Please provide the following information. All fields marked with an asterisk (*) are required.

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*member plan id no.

*Are you filing this grievance or appeal on behalf of someone else?

Yes, I am a requestor

No, I am the member

Please provide documentation showing the authority to represent the member if it was not submitted previously. Representatives include family members, friends, caregivers or providers who the member authorized in writing or others legally able to act on behalf of the member, such as someone who holds power of attorney or the member’s legal guardian. You can mail, fax or email the documentation directly to us. You can find all our contact information on our “Contact us” page.

3. Your information

Please provide your information in the following fields. All fields marked with an asterisk (*) are required.

*Name

*Relationship Your relationship to member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Important note: expedited decision

If you or your provider believes that waiting 30 days for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your provider indicates that waiting 30 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your provider’s support for an expedited appeal, we will decide if your case requires a fast decision.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, attach it to this request.

*Signature

*Date Today's date

*Signature Type

Filing a complaint with the California Department of Managed Health Care (DMHC)

The California DMHC 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 1-855-772-9076 (TTY: 711) and use your health plan’s grievance process before contacting the department. Using 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 (1-888-466-2219), and a TDD line, 1-877-688-9891, for the hearing and speech impaired. The department’s website at HMOHelp.CA.gov has complaint forms, IMR application forms and instructions online.

What's covered?

Apply or renew

For members

Grievance or appeal form

I want to report a grievance or appeal

Important note: expedited decision

Filing a complaint with the California Department of Managed Health Care (DMHC)