Medi-Cal Cancellation of Healthcare Coverage Grievance Form

Please complete this form to file a grievance. Receipt from you will be acknowledged within five working days. All grievances will be resolved within 30 days whenever possible. If your grievance is urgent or an emergency please call the Plan toll-free at (877) 433-6825, for an immediate review. Members who file a grievance against the Plan will not be discriminated or retaliated against in any way.

Please briefly explain your license request below

Member Information

Member Name*

Member Date of Birth*

Parent/Guardian Name (if completed for a minor child)

Membership Number*

Member Mailing Address*

City*

Member Zip*

Email*

Employer (if applicable)*

Name(s) of All Enrollees Affected*

Member ID Number(s) of All Enrollees Affected*

Health Plan Name

Medi-Cal ID Number (if applicable)

Medicare or Medicare Advantage ID Number (if applicable)

Medical Group (if applicable)

Grievance Information

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

Date Member filed a grievance with an entity other than the DMHC (if applicable)

If Available, Please Provide:

Copies of plan notice(s) and correspondence(s) received if any
Copies of any correspondence(s) sent by the Member
Copies of proof of payment for the last paid coverage period

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.

Member, Legal Guardian, or Parent Name*

Date*

Describe the Incident and Your Grievance*

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 (1-877-433-6825) 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 www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

PREVENTISTRY PULSE

A newsletter with tips and information to improve your oral health.

Dental benefits are provided by California Dental Network. California Dental Network does business as DentaQuest. Throughout this webpage, California Dental Network is referred to as DentaQuest.

California Dental is licensed by the California Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act, which is one of the most comprehensive regulatory programs in the United States. Information about the Department of Managed Health Care and the plans they regulate can be found on their website at www.dmhc.ca.gov.

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