Grievance Form For California Managed Care Members (Page 2 of 3) in pdf

__________________________________________________________________________________

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 (see the page with health plan

contact information)

Date___________ Member Signature: _________________________________________

Date __________ Signature of Representative

_________________________________________

NOTICE TO THE MEMBER OR YOUR REPRESENTATIVE:

The California Department of Managed Health 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: --

// ). 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.

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Grievance Form For California Managed Care Members Page 2