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Community Health Group
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Member Handbook (EOC)

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

Medi-Cal

Public program for low income people

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CommuniCare Advantage

Medicare and Medi-Cal benefits

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Community y Más

Medicare plan for chronic care needs

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File a Complaint

Also known as Grievance

Resources for Members

Grievance Form

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GRIEVANCE INFORMATION/REASON











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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 need help in your language call Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Aids and services for people with disabilities, like documents in braille and large print, are also available. Call Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). These services are free of charge.

Español (Spanish)
ATENCIÓN: si necesita ayuda en su idioma, llame al Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). También ofrecemos asistencia y servicios para personas con discapacidades, como documentos en braille y con letras grandes. Llame al Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Estos servicios son gratuitos.

Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng gọi số Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Chúng tôi cũng hỗ trợ và cung cấp các dịch vụ dành cho người khuyết tật, như tài liệu bằng chữ nổi Braille và chữ khổ lớn (chữ hoa). Vui lòng gọi số Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Các dịch vụ này đều miễn phí.

Tagalog (Tagalog - Filipino)
ATENSIYON: Kung kailangan mo ng tulong sa iyong wika, tumawag sa Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Mayroon ding mga tulong at serbisyo para sa mga taong may kapansanan,tulad ng mga dokumento sa braille at malaking print. Tumawag sa Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Libre ang mga serbisyong ito.

简体中文 (Chinese)
请注意：如果您需要以您的母语提供帮助，请致电 Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584)。另外还提供针对残疾人士的帮助和服务，例如盲文和需要较大字体阅读，也是方便取用的。请致电Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584)。这些服务都是免费的。

العربیة (Arabic)
تنبيه: إذا كنت بحاجة إلى المساعدة بلغتك، اتصل بـ Medi-Cal: ‎1-800-224-7766 ، أو بـ CommuniCare Advantage: ‎1-800-224-7766‏ (الهاتف النصي: ‎1-855-266-4584). تتوفر أيضًا مساعدات وخدمات للأشخاص ذوي الإعاقات، مثل المستندات بطريقة برايل والطباعة الكبيرة. اتصل بـ Medi-Cal: ‎1-800-224-7766، أو بـ CommuniCare Advantage: ‎1-800-224-7766‏ (الهاتف النصي: ‎1-855-266-4584). هذه الخدمات مجانية.

فارسی (Farsi)
توجه: اگر به کمک به زبان خود نیاز دارید، با Medi-Cal: ‎1-800-224-7766 یا CommuniCare Advantage: ‎1-800-224-7766‏ (TTY: ‎1-855-266-4584) تماس بگیرید. کمک‌ها و خدمات برای افراد دارای ناتوانی، مانند اسناد بریل و چاپ درشت نیز در دسترس هستند. با Medi-Cal: ‎1-800-224-7766 یا CommuniCare Advantage: ‎1-800-224-7766‏ (TTY: ‎1-855-266-4584) تماس بگیرید. این خدمات رایگان هستند.
Русский (Russian)
ВНИМАНИЕ! Если вам нужна помощь на вашем родном языке, звоните по номеру Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Также предоставляются средства и услуги для людей с ограниченными возможностями, например документы крупным шрифтом или шрифтом Брайля. Звоните по номеру Medi-Cal: 1-800-224-7766, CommuniCare Advantage: 1-800-224-7766 (TTY:1-855-266-4584). Такие услуги предоставляются бесплатно.