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GRIEVANCE FORM

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Dear Member:

The following is a Grievance, Complaint, and Appeal Form that you may complete to register your dissatisfaction with any aspect of your experience with CONCERN. If you need help in filling out this form, please call us at 800-344-4222. Within 5 days of receipt of your complaint, you will receive an acknowledgement letter. A Statement of Resolution will be sent within 5 days of our making a decision concerning your complaint, but not later than thirty days from the receipt of your complaint. You may receive our correspondence by mail or email.

You may also use this form to appeal the resolution of a previously filed complaint. By law, all grievances must be resolved within thirty (30) days of receipt of the complaint. Grievance complaints may be eligible for expedited review in cases involving an imminent and serious threat to the member’s health, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. If you have any questions regarding the grievance process, eligibility for expedited review, or your specific grievance, please call 800-344-4222.

Please be aware we may wish to contact you by phone to discuss details of your complaint to ensure a satisfactory resolution. Be sure to provide, in the section below, a phone number where you can be reached should further discussion be necessary.

You may also use this form to appeal the resolution of a previously filed complaint.

If you have any questions regarding the grievance process or your specific grievance, please contact a Clinical Manager at 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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