Contact Us Contact Us
|
  • English
  • Spanish
  • Vietnamese
  • Arabic
  • Tagalog
  • Farsi
  • Chinese/Mandarin
  • Other Language
Community Health Group
Provider Login Member Login

Member Handbook (EOC)

Select your health plan to view the Member Handbook (EOC)

Medi-Cal

Public program for low income people

Select plan

CommuniCare Advantage

Medicare and Medi-Cal benefits

Select plan

Community y Más

Medicare plan for chronic care needs

Select plan

Appeal Form

Community Health Group

If you don’t agree with Community Health Group’s decision in denying your medical service, you can ask for an appeal. You must request an appeal within 60 calendar days from the date on the denial or Notice of Action (NOA) was sent to you. You may call CHG to file an appeal verbally.

Appeal Form

* Required Field




APPEAL INFORMATION/REASON





Electronic Signature: By typing your name in the Electronic Signature Box, you agree that your electronic signature constitutes a legal signature. By selecting “Submit” button you attest that you have completed this form and the information is true to your 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 your health plan at (1-800-224-7766) 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.

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 website: 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 may be eligible for an IMR if you believe the decision was denied on the grounds that it was not medically necessary.

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 Ombuds 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.
 




English
ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Español (Spanish)
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tagalog (Tagalog - Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

简体中文 (Mandarin)
请注意：如果您使用简体中文，可为您免费提供语言协助服务。请致电：加州医疗补助计划 Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

العربیة (Arabic)
ملحوظة: اذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم
Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584)

فارسی (Farsi)
توجه: اگر به زبان فارسی صحبت می‌کنید، خدمات کمک زبانی، بدون پرداخت هزینه، در اختیار شماست. با این مراکز تماس :بگیرید
Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584)