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Medi-Cal Appeal or Grievance Form

If you believe a delay in the decision making may impose an imminent and serious threat to your health, please contact customer service at 1-800-675-6110

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, download the Grievance Form.

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

Which would you like to file? required *
Are you filing this for yourself or another person? required *

Information About Member

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

Best way to contact you? required *
OK to leave a confidential message? required *

Issue Details

MM/DD/YYYY
Do you have a denial letter?

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.

Terminally Ill Conference Request

Please let us know if you are requesting a conference

If you have received a denial for coverage and you have an incurable or irreversible condition that has a high probability of causing death within one year or less, for treatment, services or supplies deemed experimental as recommended by a Participating Plan Provider, you may request a conference. Please let us know below if you are requesting a conference. Upon receiving your request, within 30 calendar days, Health Net Community Solutions (Health Net) will provide you the opportunity to attend a conference. The conference is held within 5 business days, if your doctor, after consultation with the Health Net Chief Medical Officer or designee, determines that the effectiveness of the proposed treatment, services, alternate treatment, or supplies covered by the plan, would be materially reduced if not provided at the earliest possible date.

Conference Request

A message to State Health Program 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 (1-800-675-6110, TTY: 711) 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.

Last Updated: 05/07/2026