Appeal or Grievance Form

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 one of the forms below.

Health Net encourages you to provide a detailed account of your experience. Your feedback is important to us and we appreciate the time you have taken to share this information. We hope that you will allow us to continue to serve you and provide the excellent service that you deserve.

If you believe a delay in the decision making may impose an imminent and serious threat to your health, please contact customer service using the toll-free telephone number on your ID card to request an expedited review.

Should I file an Appeal or Grievance?

Appeal

File an Appeal when appealing the denial of a service or benefit.

Grievance

File a Grievance to formally express your dissatisfaction with care or service(s) you've received.

Your Appeal or Grievance will be submitted to the Appeals & Grievances Department for review.

Type of Issue

* = Required Field

Which would you like to file? *

An Appeal A Grievance

Information About Person Completing this Form

First Name *

Last Name *

Relationship to Member *

Self Child Parent Spouse Other

If Other, please specify

Information About Member

Member ID *

Member First Name *

Member Last Name *

Current Home Address *

City *

State *

Postal/Zip Code *

E-mail Address *

Telephone Number *

Please Note: It is critical to our investigation that we have a way to contact you with any questions we may have regarding your complaint. If you cannot provide a phone number please advise the best way to contact regarding this matter.

Best way to contact you? *

Phone Mail

OK to leave a confidential message? *

Yes No

Issue Type

Claim Issue Coverage Issue Other

Date of Service/Occurrence * MM/DD/YYYY

Do you have a denial letter?

Yes No

Please include to the best of your ability all relevant dates, names of individuals directly involved, any phone numbers where you made contact or addresses of visits, billed amounts, any specifics on the type of service/provider you are attempting to access any other details that you believe will assist in the investigation or resolution of this matter.

Description of the concern or issue? *

If you are not the member and are filing on the member's behalf please fax or email appropriate authorization paperwork to:

Customer Call Center:

If you enrolled directly with Health Net, call 1-800-839-2172.
If you enrolled through Covered California, call 1-888-926-4988.

Fax#: 877-831-6019

Manual Member Appeal/Grievance Form and Filing Instructions

A message to Heath Net of California Commercial members, from the 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 1-800-522-0088, TTY: 711 and use your health plans 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 departments internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

File an Appeal or Grievance