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Member Grievance/Appeals Forms


Please fill-up the online form OR you may download and fill-up the Member Grievance/Appeals Form and mail or fax to:
Contra Costa Health Plan
Member Services Dept.
Attn: Grievance/Appeal
595 Center Ave., Suite 100
Martinez, CA 94553
Phone: 1-877-661-6230, Press 2
Fax: 925-313-6047

Online Grievance/Appeal Form

Member Name
First Name

MI

Last Name
Date of Birth
(mm/dd/yyyy)
Member ID Number
Phone
(include extension if needed)
Email
see our privacy policy
Address
Date of Service
(mm/dd/yyyy)
Location of Service
Briefly Describe Complaint
(Please include as much detail as possible including names of the people involved, the circumstances leading up to the conflict, and any information you feel is important to the complaint)
What action are you requesting?

Information Needed to File an Appeal

  • Appeal/Reconsideration requests can be made to the Health Plan by the member if they have received a Notice of Action (NOA) letter concerning a denial of a claim or a delay, modification or denial of a requested service.
  • The request can be made by phone or on-line but must be followed up in writing and signed by the member or the member’s legal representative.
  • For our Medi-Cal members this request must be made within 60 days of receipt of a NOA.
  • For our Commercial member this request must be made within 180 of a receipt of a NOA.
  • Date of Notice of Action (NOA) Denial Letter:
Description of a Regular Appeal
(Please include as much detail as possible including date of the denial of the claim or service and any additional information you feel is important to consider. The Health Plan has 30 days to respond to your appeal and you will get a final notice of resolution)
Description of an Expedited Appeal
(If you think waiting 30 days for the Health Plan to respond, will hurt your health, you might be able to get a response within 72 hours. When filing your appeal, say why waiting will hurt your health. Make sure you ask for an "expedited appeal". Please include as much detail as possible including date of the denial of service and any additional information you feel is important to consider. The Health Plan has 72 hours to respond to your expedited appeal and you will get a final notice of resolution)

Person Completing form if other than member

Name of Person Submitting form
Relationship Spouse     Parent     Grandparent Guardian
if none of the above, please specify:
Phone

If not authorized by member or member's legal guardian, we will be unable to process grievance/appeal without member's explicit agreement.


If you experience any difficulties with this form, please contact us at 1-877-661-6230 (press 2).

FILING A COMPLAINT WITH DEPARTMENT OF MANAGED HEALTH CARE (DMHC)

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance/appeal against your health plan, you should first telephone your health plan at 1-877-661-6230 (press 2) and use your health plan’s grievance/appeal process before contacting the department. Utilizing this grievance/appeal procedure does not prohibit any potential legal rights or remedies that may be available for you. If you need help with a grievance/appeal involving an emergency, a grievance/appeal that has not been satisfactorily resolved by your health plan, or a grievance/appeal 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.