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Commercial Appeal or Grievance Form

Many issues or concerns can be promptly resolved by our Member Services Department. If you have not already done so, you may want to first contact Member Services before submitting one of the forms below.

Health Net of California, Inc. and/or Health Net Life Insurance Company (collectively, Health Net) encourages you to provide a detailed account of your experience. Your feedback is important to us and we appreciate the time you have taken to share this information.

If you believe a delay in the decision making may impose an imminent and serious threat to
your health, please contact customer service at:
Small Group Plans through Covered California 1-888-926-5133 TTY 1-888-926-5180
Group Plans through Health Net 1-800-522-0088 TTY 1-800-995-0852
Medicare Group 1-800-275-4737

If you prefer to file a grievance by mail or fax, or if you need to complete the form in another language other than English

What should I do?

Appeal

File an Appeal when appealing the denial of a service or benefit

Grievance

File a Grievance to formally express your dissatisfaction with care or service(s) you have received

Type of Issue

* = Required Field


Information About Member

Please Note: Please tell us how to contact you in case we have questions about your appeal or grievance.


Issue Details

MM/DD/YYYY

Please include to the best of your ability all relevant dates, names of individuals directly involved, any phone numbers where you made contact or addresses of visits, billed amounts, any specifics on the type of service/provider you are attempting to access any other details that you believe will assist in the investigation or resolution of this matter.

A message to Heath Net of California Commercial members, from 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:

  • Small Group Plans through Covered California 1-888-926-5133 TTY 1-888-926-5180
  • Group Plans through Health Net 1-800-522-0088 TTY 1-800-995-0852

and use your health plans 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 departments internet website www.dmhc.ca.gov as complaint forms, IMR application forms and instructions online.

A message to Heath Net of California Medicare Group members

Wellcare By Health Net will have a resolution to your complaint no later than 30 days after your submission. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

However, if we take this extension, we will notify you or your representative. We can usually help you right away or at the most within a few days. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal”, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

If you need any help, please call us at 1-800-275-4737 (TTY: 711). From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. You can also visit www.Wellcare.com/healthnetCA.

Last Updated: 06/20/2022