*Any group member, employee or individual who is eligible to enroll for benefits in accordance with the plan's conditions of eligibility.
Note: If you are submitting a grievance on behalf of a dependent age 18 or older, federal HIPAA regulations require us to obtain signed authorization from that dependent in order to release his or her personal health information.
MP-Northern Mariana Islands
Please describe the nature of your complaint (include dates and names of persons involved).
Is this complaint about a dental provider?
Dental Provider City
Phone Number (
When was treatment provided?
(mm/dd/yyyy) Was it completed?
Have you discussed your grievance with the dental provider, the provider's staff or anyone at Delta Dental?
If an agreeable solution can be reached, would you return to the treating dental provider?
Note: A copy of this grievance form may be forwarded to the treating dental provider.
If you prefer to mail or telephone your grievance, contact us at:
Delta Dental of California
PO Box 997330
Sacramento, CA 95899-7330 Toll-free number
The law requires the following be placed on all plan grievance forms:
For California Enrollees:
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 1-800-765-6003 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.
The plan will acknowledge receipt of your grievance within 5 days. The plan will issue a written decision on your grievance within 30 days, or 60 days if your group health plan is subject to the Employment Retirement Income Security Act of 1974 (ERISA).
If your health plan is covered under ERISA, you may also contact the Employee Benefits Security Administration for further review of the claim or if you have questions about your rights under ERISA. The address is Employee Benefits Security Administration, 200 Constitution Avenue, N.W., Washington, DC 20210.