Grievance & Appeal Form

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Required fields are indicated with an asterisk (*)

Member Information

First Name

Last Name

Middle Initial

Member ID#

Primary Care Provider

Birth date

Email (Optional)

Confirm email

Daytime phone number

Evening phone number

Home Address

City/Town

State/Province

ZIP/Postal Code

Mailing address: (if different from home address)

City/Town

State/Province

ZIP/Postal Code

Submitter Information (If submitter is different than member)

First Name

Last Name

Middle Initial

Relationship to Member

Daytime phone number

Evening phone number

Address

City/Town

State/Province

ZIP/Postal Code

The member can name a relative, friend, advocate, attorney, doctor, or someone else to act for them. The person that acts on their behalf, authorized representative, requires signed permission.

Do you have documented signed permission to act on the Member's behalf?

Yes

If Yes, please attach a copy of the document(s).

One file only.
25 MB limit.
Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx.

If No, please continue with completing the grievance form and L.A. Care will contact you to help with the next steps.

Description of Concern

Involved Doctor or Provider full name:

Doctor/Provider Phone number

Where did the problem occur? (Name of Pharmacy, Hospital, Medical Office, etc.)

Date of Incident

Who was involved beside yourself? (Give names of involved staff, if possible)

Briefly outline the specific details of the problem and identify when the event(s) occurred. PLEASE BE SPECIFIC. Please include a statement regarding the outcome desired and what you believe the Plan can do to resolve your concern. If you have copies of documents, bills, checks, or other correspondence related to this problem that may help in the investigation and resolution, please include them with this form. If this involves a denial, please include the denial reference number. If you need more pages to describe the issue, please attach them to this form.

Date member received notice that coverage was or will end: (if applicable)

Are copies of member correspondence attached? (if applicable)

Yes

A Complaint (or Grievance) is when you have a problem with L.A. Care or a provider, or with the health care or treatment you got from a provider.

An Appeal is when you don't agree with L.A. Care's decision not to cover or change your services.

Are you filing a Grievance or an Appeal?

Grievance

Appeal

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You can also download the PDF version of the form and submit by mail or in person to:

Attention: Appeals & Grievances L.A. Care Health Plan
1200 W. 7th Street
Los Angeles, CA 90017

Or by Faxing to:
Attention: Appeals & Grievances 213-428-5748

Medi-Cal, Medicare Plus, Covered California, PASC-SEIU Members

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 1-888-839-9909 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 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 department's internet website http://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

If you have any other questions or concern(s) on this matter, please call L.A. Care at 1-888-839-9909.

Medi-Cal & Medicare Plus Members

California Department of Health Care Services (DHCS) Office of the Ombudsman

You may also call the Ombudsman Office of the California Department of Health Care Services (DHCS) for help. The Ombudsman Office helps Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. To find out more, call toll-free 1-888-452-8609 Monday through Friday, 8am to 5pm PST; excluding holidays..

State Hearing

You may ask for a State Hearing within 120 days of receiving the Notice of Appeal Resolution from L.A. Care. You may either present your case yourself, or ask someone to present your case, such as legal counsel, relative, friend, or any other person. For more about State Hearing requests, please call 1-800-952-5253 Monday through Friday, 8:00 a.m. to 5:00 p.m.; excluding holidays. For the hearing impaired TDD, please call 1-800-952-8349. To request a State Hearing in writing please send your letter to the following address:

California Department of Social Services
State Hearing Division
P. O. Box 944243, MS 19-37
Sacramento, CA 94244-2430

Medicare Plus Members

You can contact Centers for Medicare & Medicaid Services (CMS) with complaints about Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. (You can also read or download “Medicare Rights & Protections,” found on the Medicare website at www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)

If you need assistance, we’re here to help. You can call L.A. Care Member Services at 1-888-839-9909. We are available to assist you 24 hours a day 7 days a week including holidays.

Member Information

Submitter Information (If submitter is different than member)

Description of Concern

Medi-Cal, Medicare Plus, Covered California, PASC-SEIU Members

Department of Managed Health Care

Medi-Cal & Medicare Plus Members

California Department of Health Care Services (DHCS) Office of the Ombudsman

State Hearing

Medicare Plus Members

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