GRIEVANCE OR EXPRESSION OF DISSATISFACTION
You may complete and submit the form below to file a grievance. We will notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," or we decided we need more time to review your request for a medical care or appeal of denied medical care we will automatically give you a "fast complaint" and respond to your complaint within 24 hours. If you have an urgent problem that involves an immediate and serious risk to your health, you can request a "fast complaint" and we will respond within 72 hours.
(A Grievance form is not required for a "Fast Complaint" you may also file one verbally by calling 1-855-464-3571 for Los Angeles Members and 1-855-464-3572 for San Diego Members.)
- Who May Make a Request
You (the enrollee), your provider or your representative can request a grievance. Representation documentation is required for grievance requests made by someone other than the Enrollee or the Enrollee's provider. Attach documentation showing the authority to represent the Enrollee (a completed Authorization of Representation Form CMS-1696 (pdf) or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our Customer Service Department.
(In addition, Cal MediConnect may also accept other forms of legal documentation)