DELTACARE® USA ENROLLEE 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 Patient Information
       
Enrollee*
First Name
Patient
First Name
Enrollee Last Name Patient Last Name
Enrollee ID Patient Date of Birth / / (mm/dd/yyyy)
Enrollee Date of Birth / / (mm/dd/yyyy)    
       
*Any group member, employee or individual who is eligible to enroll for benefits
in accordance with the plan's conditions of eligibility.
       
Street Address    
City    
State    
ZIP Code -    
       
Nature of Grievance
Please include dates and names of persons involved.
       
Is this complaint about a dental provider? Yes No    
Facility Name Facility Phone Number ( ) -
       
Additional Information
Have you discussed your grievance with anyone at the facility or anyone at Delta Dental?
Dental Provider Facility Staff Delta Dental  
 
If yes, what was the outcome of your discussion?
 
Please state your desired outcome:
 
E-mail Address    
 
Note: A copy of your correspondence may be forwarded to the facility unless you state otherwise. Electronic submission of this grievance form authorizes the plan to obtain from any facility(s) all pertinent material required 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 (or 60 days if your group health plan is subject to the Employment Retirement Income Security Act of 1974 [ERISA]).

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 (1-800-422-4234) 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.

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.

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

DeltaCare USA
Quality Management Department


P. O. Box 6050
Artesia, CA 90702

Toll-free number
(800) 422-4234

Or you may fax to:
(562) 924-6914

       
       
   
  © 2006 Delta Dental