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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 CA 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 1-800-926-4178 TTY 711

**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 (PDF) in English or Spanish.

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?

Description of the concern or issue? *

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.

Health Net collects some private data about site visitors. Learn more about the data we collect or request your data be removed

Do Not Sell My Personal Information

DISCLAIMERS:

Health Net Life is soliciting to sell health insurance. A salesperson may call. Health Net Life is not connected with or endorsed by the U.S. Government or the Federal Medicare program. The Health Net Medicare Supplement plan is underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company holds a Certificate of Authority in California and 48 other jurisdictions throughout the United States.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year.

Health Net Life complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak Spanish or Navajo, language assistance services, free of charge, are available to you. Call 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: TTY: 711).

This plan is available to anyone who has both Medical Assistance from the State and Medicare.

Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Medicare beneficiaries may also enroll in Bridgeway Health Solutions through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.


Health Net collects some private data about site visitors. Learn more about the data we collect or request your data be removed

Do Not Sell My Personal Information

DISCLAIMERS:

Health Net Life is soliciting to sell health insurance. A salesperson may call. Health Net Life is not connected with or endorsed by the U.S. Government or the Federal Medicare program. The Health Net Medicare Supplement plan is underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company holds a Certificate of Authority in California and 48 other jurisdictions throughout the United States.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year.

Health Net Life complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak Spanish or Navajo, language assistance services, free of charge, are available to you. Call 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: TTY: 711).

This plan is available to anyone who has both Medical Assistance from the State and Medicare.

Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Medicare beneficiaries may also enroll in Bridgeway Health Solutions through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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