Medi-Cal 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 ID Number

Subscriber Name (if different from above)

Subscriber ID Number (if different from above)

Day Phone

Evening Phone

Grievance Information

Plan Facility Facility personnel Treating provider

Facility Information

Facility Name

Facility ID Number

Facility Address

Treating Provider Name

List the name(s) of facility personnel you spoke with about this matter

Describe the Incident and Your Grievance

Yes

Your Name

I give permission to California Dental Network, Inc. to discuss this Grievance with the person(s) named below, including any pertinent medical/dental records and/or personal health information needed to assist in the processing of this Grievance.

Definitions for Grievance Procedures

"Grievance" means a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by an enrollee or the enrollee's representative.
"Complaint" is the same as "grievance."
"Complainant" is the same as "grievant," and means the person who filed the grievance including the enrollee, a representative designated by the enrollee, or other individual with authority to act on behalf of the enrollee.
"Resolved" means that the grievance has reached a final conclusion with respect to the enrollee's submitted grievance, and there are no pending enrollee appeals within the plan's grievance system, including entities with delegated authority.
“Pending” grievances that are not resolved within 30 calendar days, or grievances referred to the Department's complaint or independent medical review system.

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.

Medi-Cal Nondiscrimination Notice - Sacramento County
Medi-Cal Nondiscrimination Notice - Los Angeles County