Grievance & Appeal Form | L.A. Care Medicare

Required fields are indicated with an asterisk (*)

Name of person completing this form

Phone number of person completing this form

Relationship to Member

Member's Name

Current Home Street Address

Apt

City

Zip

Member Phone Number

Member ID Number

Members Date of Birth

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?

Description of incident

Involved Provider (i.e. PCP, Medical Group, LA Care)

Location of incident

Date of Incident

Description of service denied

Involved Provider (i.e. PCP, Medical Group, LA Care)

Do you have a signed denial letter?

Date of Denial Letter

Have services already been performed?

Date of Service

Reason for Appeal

CAPTCHA

Member Rights

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.

Additional Rights for Medi-Cal Members

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. 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

California Department of Health Care Services (DHCS) Office of the Ombuds Program

You may also call the Ombuds Office of the California Department of Health Care Services (DHCS) for help. The Ombuds 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.

Ombuds Program: This special program can tell you about your options, including helping you file an appeal or grievance, or helping you set up a fair hearing. 1-855-501-3077

1-800-MEDICARE: You can contact this program with questions about your Medicare benefits at 1-800-633-4227