Appeals

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Additional Questions

State where Service was Provided

Are you appealing/disputing on behalf of the member?

Yes

Does the member have Medicare coverage?

Yes

Expedited Review

The Plan makes every effort to process your appeal as quickly as possible. In some cases, you have a right to an expedited 72-hour appeal if your health or ability to function could be seriously harmed by waiting for a standard appeal, which may take up to 30 days. You may file an oral or written request for a 72-hour appeal. Call, write or fax the Plan. Ask for an “expedited review,” a “72-hour review,” or say, “I believe my health could be seriously harmed by waiting for a standard review.”

Call:
1-800-445-9090 (5 a.m. - 8 p.m. Pacific)
TTY 771

Write:
Grievances and Appeals, MS CA160-0293
P.O. Box 30569
Salt Lake City, CA 84130-0569

Fax:
(714) 364-6266

For All California Members

If a complaint has been sent for immediate expedited review, the Plan will immediately inform you in writing of your right to notify the Department of Managed Health Care of the grievance. The Plan will provide you and the Department of Managed Health Care with a written statement of the disposition of pending status of the expedited review no later than three days from receipt of the complaint.

The following language is required by the Department of Managed Health Care:

“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 1-800-445-9090 or TTY 771 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 be 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 the 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 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.”

Claim Search

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Claims

Pre Treatment Estimates

Service Date Range

Search is limited to dates within the past 2 years.

Refer to the EOB for specific instructions and guidelines for timely appeal filing.

Claim List

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Dentist Name

Office Location

Date of
Service

Amount
Claimed

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Status

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Does this request qualify for an expedited appeal?

An appeal may qualify for expedited status if the patient's medical condition is such that the time needed to complete a standard appeal could seriously jeopardize the patient's life, health or ability to regain maximum function

Yes

Claim ID:

Claim Status:

Date Processed:

Member Name:

Relationship:

Primary

Dentist:

Abby Wilentz

Date Received:

Primary

Check Number:

67706880

Check Issue Date:

Other Insurance Paid:

$ 0.00

Total Patient
Responsibility:

$ 186.00

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Amount

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Upload Documents

Please upload any supporting documentation relevant to the appeal, as well as any documents not included with your initial claim submission..

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Required Documents

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5 MB

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Provide a summary of your concern(s), including as much detail as possible

Expedited Review

Call:
1-800-445-9090 (5 a.m. - 8 p.m. Pacific)
TTY 771

Write:
Grievances and Appeals, MS CA160-0293
P.O. Box 30569
Salt Lake City, CA 84130-0569

Fax:
(714) 364-6266

For All California Members

The following language is required by the Department of Managed Health Care:

Review and Sign

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Provider & Member Information

Provider Name

Provider Phone #

Provider Tax ID #

Member Name

Member ID

Member Date of Birth

Are you appealing/disputing on behalf of the member?

Does the member have Medicare coverage?

Claim Information

Does this request qualify for an expedited appeal?

Claim #

Date of Service

State where Service was Provided

Uploaded Documents

Summary of Concern(s):

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Today's Date

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