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GRIEVANCE FORM

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Dear Member:

The following is a Grievance Complaint Form that you may complete in order to expedite your complaint. If you need help in filling out this form, please call us at 1-800-344-4222. You will receive an Acknowledgement of Receipt of Complaint letter within five days of receipt of the complaint and a Statement of Complaint Resolution letter within five days of a decision, but no later than thirty calendar days from receipt of the complaint. The Acknowledgement of Receipt of Complaint letter acknowledges that we received your complaint. 

If you have any questions regarding the grievance process or your specific grievance, please contact a Clinical Manager at 1-800-344-4222. By law, all grievances must be resolved within thirty (30) days of receipt of the complaint.

Attention California Members:

Please review the following information.

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 1-800-344-4222 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that might 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 and aTDD line 1-877-688-9891 for the hearing and speech impaired. The department's Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

You may also want to print a copy of this page for your records by using your browser print command before you submit your final information.

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