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What is your name?
Member Number
Who received or was seeking the service?
Member Number


State   Zipcode   Phone Number

Who was the Primary Care Provider at the time you/family member received or was seeking the service?

Date this Grievance is being filed:
Does this grievance involve an imminent and serious threat to health, severe pain, or potential loss of life, limb, or major bodily function?

What is the reason for grievance? (Check all that apply or explain under Other)
Availability of Service Issues (couldn't get care
Not satisfied with response to a complaint
Access to Care Issues (waiting time in office, etc.) Service or Authorization for Service
     was denied
Provider Dissatisfaction (didn't like
     provider / staff, etc.)

Please briefly describe the situation you want CHG to review

Please check here if you would like CHG's Member Advocate to assist with your appeal.

1.Where did you receive or from whom did you request the service?
2.When did you receive or request the service? ( MM/DD/YYYY )
3.Is there anything else we should know about your appeal?
This information is true to my knowledge.

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 Community Health Group (CHG) at (800) 224-7766 toll-free and use CHG'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 www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
If you are dissatisfied with a "medical necessity" decision of CHG, you may request an IMR from the California Department of Managed Health Care. If you believe you are eligible for an IMR, please contact us immediately and we will provide an IMR Application Form to you. You may also obtain an IMR application form at the Department of Managed Health Care internet web site: www.dmhc.ca.gov. If you are not sure whether you are eligible for an IMR or want more information, please contact CHG’s Customer Service Department at 1-800-224-7766 toll free.

Decisions which are eligible for IMR are those where CHG or a CHG contractor decided that the request for care or service was not medically necessary. Requests for benefits beyond those included in the benefits package are not eligible for IMR.

IMR is done by an independent review organization (IRO). An IRO is not connected in any way with CHG, and is under contract with the Department of Managed Health Care. CHG must go along with the IRO’s decision and carry out its instructions, as required by the Department of Managed Health Care. You are not responsible for the costs of the IMR.

To be eligible for an IMR, you must request the IMR within 180 days (six months) of the date you were notified of a decision to deny, delay or modify authorization or payment for a health care service. If you do not request the IMR within that time, it cannot be reviewed by the IRO, unless the Department of Managed Health Care requires otherwise.

As a Medi-Cal member, you may also call the California Department of Health Services Medi-Cal Managed Care Ombudsman at 1-888-452-8609 or request a fair hearing by the State Department of Social Services by calling 1-800-952-5253. You may request a fair hearing without first going through the appeal process, or may request a fair hearing at any time during the appeal process.