Appeals and Grievances
Many issues or concerns can be promptly resolved by our Member Services Department. If you have not already done so, you may want to first contact Member Services before submitting an appeal or grievance.
Member tip: Check the back of your ID card for your phone contact information.
File a GRIEVANCE FORM – Online
File a GRIEVANCE FORM – Mail or Fax
Ambetter from Health Net Plans
- Ambetter from Health Net Member HMO-POS Plan – GRIEVANCE FORM – English (PDF)
- Ambetter from Health Net Member HMO-POS Plan – GRIEVANCE FORM – Spanish (PDF)
- Ambetter from Health Net Member HMO-POS Plan – GRIEVANCE FORM – Chinese (PDF)
- Ambetter from Health Net Member HMO-POS Plan – GRIEVANCE FORM – Korean (PDF)
- Ambetter from Health Net Member HMO-POS Plan – GRIEVANCE FORM – Vietnamese (PDF)
Employer Group Plans
- Employer Group Member HMO-POS Plan – GRIEVANCE FORM – English (PDF)
- Employer Group Member HMO-POS Plan – GRIEVANCE FORM – Spanish (PDF)
- Employer Group Member HMO-POS Plan – GRIEVANCE FORM – Chinese (PDF)
- Employer Group Member HMO-POS Plan – GRIEVANCE FORM – Korean (PDF)
- Employer Group Member HMO-POS Plan – GRIEVANCE FORM – Vietnamese (PDF)
Ambetter from Health Net Plans
- Ambetter from Health Net Member PPO-EPO Plan – GRIEVANCE FORM – English (PDF)
- Ambetter from Health Net Member PPO-EPO Plan – GRIEVANCE FORM – Spanish (PDF)
- Ambetter from Health Net Member PPO-EPO Plan – GRIEVANCE FORM – Chinese (PDF)
- Ambetter from Health Net Member PPO-EPO Plan – GRIEVANCE FORM – Korean (PDF)
- Ambetter from Health Net Member PPO-EPO Plan – GRIEVANCE FORM – Vietnamese (PDF)
Employer Group Plans
- Employer Group Member PPO-EPO Plan – GRIEVANCE FORM – English (PDF)
- Employer Group Member PPO-EPO Plan – GRIEVANCE FORM – Spanish (PDF)
- Employer Group Member PPO-EPO Plan – GRIEVANCE FORM – Chinese (PDF)
- Employer Group Member PPO-EPO Plan – GRIEVANCE FORM – Korean (PDF)
- Employer Group Member PPO-EPO Plan – GRIEVANCE FORM – Vietnamese (PDF)