Medi-Cal – Appeals and Grievances
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 Community Solutions 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 1-800-675-6110.
File a GRIEVANCE FORM – Online
File a GRIEVANCE FORM – Mail or Fax
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 and print a GRIEVANCE FORM.
- Member GRIEVANCE FORM – English (PDF)
- Member GRIEVANCE FORM – En Español (Spanish) (PDF)
- Member GRIEVANCE FORM – Arabic (PDF)
- Member GRIEVANCE FORM – Armenian (PDF)
- Member GRIEVANCE FORM – Cambodian / Khmer (PDF)
- Member GRIEVANCE FORM – Chinese (PDF)
- Member GRIEVANCE FORM – Farsi (PDF)
- Member GRIEVANCE FORM – Hindi (PDF)
- Member GRIEVANCE FORM – Hmong (PDF)
- Member GRIEVANCE FORM – Japanese (PDF)
- Member GRIEVANCE FORM – Korean (PDF)
- Member GRIEVANCE FORM – Laotian (PDF)
- Member GRIEVANCE FORM – Panjabi / Punjabi (PDF)
- Member GRIEVANCE FORM – Russian (PDF)
- Member GRIEVANCE FORM – Tagalog (PDF)
- Member GRIEVANCE FORM – Thai (PDF)
- Member GRIEVANCE FORM – Vietnamese (PDF)
File a GRIEVANCE FORM – Upload PDF
File a grievance form by uploading the PDF here.
Complete your form and save it. Then click the Choose File button, and select your form. The name of your form will appear next to the button. Then click Submit.
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.