Marketplace Grievance Form

Section A: Member Information

Last Name

First Name

Initial

Date of Birth (MM/DD/YY)

Gender

Male Female Other

Mailing Address

City

State

Zip

Daytime Phone Number

Evening Phone Number

Contact Hours (Please specify when you prefer to be called)

Email Address

Date of Incident

Name and identification number(s) of all enrollees affected

Name of parent or guardian, if filing for minor child enrollee

Section B: Health Plan Information

Health Plan Name

Health Plan Membership Number

Medical Group Name (if applicable)

Employer (if applicable)

Medi-Cal Identification Number (if applicable)

Medicare or Medicare Advantage Identification Number (if applicable)

Date Enrollee Received Notice that Coverage Was or Will End (if applicable)

Date Enrollee Filed a Grievance with an Entity Other than the Department of Managed Health Care (if applicable)

Section C: Please give a detailed reason for your grievance (complaint):

Section D: Signature

I certify that the statements made in this complaint are true and correct to the best of my information and belief.

Signature

Date

If the complaint is filed by a Parent/Guardian/representative on behalf of the individual, complete the following and check the appropriate box.

Print Name of Parent/Guardian/Representative:

Signature of Parent/Guardian/Representative

Date

Parent of Minor Child Legal Guardian Power of Attorney Executor/Conservator

Other

If applicable, attach the following:

Copies of plan notice(s) and correspondence(s) received

Copies of enrollee correspondence(s)

Copies of proof of payment for the last paid coverage period

Please return this form to:

Molina Healthcare of California

Attn: Member Appeals and Grievance

200 Oceangate, Suite 100

Long Beach, CA 90802 or

Fax (562) 499-0757

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 1-888-858-2150, TTY users dial 711 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 aTDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.

PLEASE COMPLETE IF APPLICABLE

MEDICAL RELEASE

I request that the Department of Managed Health Care (DMHC) make a decision about my problem with my plan. I request that the DMHC review my Cancellation of Health Coverage Grievance Form to determine if my grievance qualifies for the DMHC's Consumer Complaint process. I allow my providers, past and present, and my plan to release my medical records and information to review this issue. These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and other records related to my grievance. These records may also include non-medical records and any other information related to my grievance. I allow the DMHC to review these records and information and send them to my plan. My permission will end one year from the date below, except as allowed by law. For example, the law allows the DMHC to continue to use my information internally. I can end my permission sooner if I wish. All the information that I have provided on this sheet is true.

Enrollee, Legal Guardian, or Parent Signature:

Date:

Please see the instruction sheet for mailing or faxing information.

PLEASE COMPLETE IF APPLICABLE

AUTHORIZED ASSISTANT FORM

If you want to give another person permission to assist you with your grievance, complete Parts A and B below.

If you are a parent or legal guardian submitting this grievance for a child under the age of 18, you do not need to complete this form.

If you are filing this grievance for an enrollee who cannot complete this form because the enrollee is either incompetent or incapacitated, and you have legal authority to act for this enrollee, please complete Part B only. Also attach a copy of the power of attorney for health care decisions or other documents that say you can make decisions for the enrollee.

PART A: ENROLLEE

I allow the person named below in Part B to assist me in my grievance filed with the DMHC. I allow the DMHC staff to share information about my medical condition(s) and care with the person named below. This information may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care information.

I understand that only information related to my grievance will be shared.

My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must do so in writing.

Enrollee Signature:

Date:

PART B: PERSON ASSISTING ENROLLEE

Name of Person Assisting (print):

Signature of Person Assisting:

Street Address:

City:

State:

Zip:

Relationship to Enrollee:

Daytime Phone Number:

Evening Phone Number:

Email Address (if available):

My power of attorney for health care decisions or other legal document is attached:

(check if applicable)

GRIEVANCE/COMPLAINT FORM INSTRUCTION SHEET

If you have questions, call the Help Center at 1-888-466-2219 or TDD at 1-877-688-9891. This call is free.

How to File:

1. File online at www.HealthHelp.ca.gov. [This is the fastest way.]

Fill out and sign the Cancellation of Health Care Coverage Grievance Form.

2. If you want someone to help you with your grievance, complete the Authorized Assistant Form.

3. Include documents requested on the Cancellation of Health Care Coverage Grievance Form, such as notices from your health plan, billing statements, and proof of payment.

4. If you are not submitting online, please mail or fax your form and any supporting documents to:

DEPARTMENT OF MANAGED HEALTH CARE

HELP CENTER

980 9TH STREET, SUITE 500

SACRAMENTO, CA 95814-2725

FAX: 916-255-5241

What Happens Next?

The Help Center will send you a letter telling you if your grievance has been accepted. If your grievance is accepted, a decision about your issue will be made within 30 days. You will be notified in writing of the decision.

INFORMATION PRACTICES ACT OF 1977 NOTICE

The Information Practices Act of 1977 (California Civil Code section 1798.17) requires the following notice.

California's Knox-Keene Act gives the DMHC the authority to regulate health plans and investigate the grievances of health plan members.

The DMHC's Help Center uses your personal information to investigate your problem with your health plan.

You provide the DMHC this information voluntarily. You do not have to provide this information. However, if you do not, the DMHC may not be able to investigate your grievance.

The DMHC may share your personal information, as needed, with the plan and providers to investigate your grievance.

The DMHC may also share your information with other government agencies as required or allowed by law.

You have a right to see your personal information. To do this, contact the DMHC Records Request Coordinator, DMHC, Office of Legal Services, 980 9th Street Suite 500, Sacramento CA 95814-2725, or call 916-322-6727.