MEMBER GRIEVANCE FORM

     
 

Please fill out this form as completely as possible. Your concerns are important to us. This information will help our investigation. We protect the privacy of sensitive information such as social security numbers.
For more information, see our Web privacy notice.

 
 
Enrollee and Dentist Information
       
Enrollee*
First Name
Patient
First Name
Enrollee Last Name Patient Last Name
Enrollee Date of Birth / / (mm/dd/yyyy)    
       
Street Address    
City    
State    
ZIP Code -    
       
Enrollee Phone Number ( ) - Message Phone (Optional) ( ) -
       
Enrollee ID Date Problem Occurred / / (mm/dd/yyyy)
       
Dental Provider Name Dental Provider Phone (Optional) ( ) -
       
(*Any group member, employee or individual who is eligible to enroll for benefits
in accordance with the plan's conditions of eligibility.)
       
Nature of Grievance
Describe your grievance completely. State the nature of the problem and persons involved. This information is important and necessary to research and resolve your grievance. Please be as specific as possible.
       
 
Please state your desired outcome:
 
E-mail Address    
       
Note: It may be necessary to obtain your medical records from your dental care provider. Electronic submission of this grievance form authorizes the plan to contact the provider listed to resolve your grievance.

The plan will acknowledge receipt of your grievance within 5 days. The plan will issue a written decision on your grievance within 30 days. If you have completed the plan's grievance process or if you have been involved in the plan's grievance process for 30 days, you may file a grievance with the California Department of Managed Health Care if the plan has not satisfactorily resolved your grievance. You may immediately file a grievance with the Department in an emergency situation which is one involving severe pain and imminent and serious threat to your health.

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 (1-877-580-1042) 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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.

IMR has limited application to your dental program. You may request IMR only if your dentist claim concerns a life-threatening or seriously debilitating condition(s) and is denied or modified because it was deemed an experimental procedure.

 
 
If you prefer to mail or telephone your grievance, contact us at:

Customer Service Department
Delta Dental of California
State Government Programs
P.O. Box 537010
Sacramento, CA 95853-7010

Toll-free number:
(877) 580-1042

       
       
   
 
  © 2006 Delta Dental