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Grievance Form


U.S. Behavioral Health Plan, California Click here for the Grievance Form in LARGE PRINT

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If you are not satisfied with any aspect of your contact with USBHPC or its representatives, please complete all sections of this form and submit it to the address listed below.

If you need assistance or additional referrals, please call the phone number for mental health services on the back of your medical card.




* Required
Your grievance is about (select one): *
Clinician or Facility
Other
Are you filling out this form for yourself or for someone else? *

  Other:
*
  

Check if address is same as enrollee's
Enrollee Information
Please fill out the following information:

For the purposes of this form, the "Enrollee" is the person to whom the services were rendered.
Enrollee First Name *
Enrollee Last Name *
Enrollee Address *
Enrollee City *
Enrollee State *
Enrollee Zip *
Enrollee Phone *
- -  Type:
Alternative Phone
- -   Type:
Enter extension or international phone number in the grievance textbox below.
Enrollee Date of Birth *    
Subscriber Name
Relationship to Subscriber    Other:  


If you are completing this form on behalf of the enrollee, please include your name, address, phone number and your relationship to the enrollee:

First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
- -   Type:
Alternative Phone
- -   Type:
Enter extension or international phone number in the grievance textbox below.



Grievance *
Please describe your grievance in as much detail as possible. Please include dates and names. Written acknowledgement of your grievance will be provided within five (5) calendar days of our receipt; written resolution to your grievance will be provided within 30 calendar days of our receipt.

Do not hit "Enter" or click the "Back" button prior to completing this section. You will have a chance to review and make revisions prior to submitting this form.



Please describe the outcome(s) you are seeking at this time.


In order to conduct a thorough investigation of this complaint, we may need to use your name. Do you wish to remain anonymous? *
No
Yes

Provider Information
Please select provider type: *
Clinician
Facility

Please provide the name, address and phone number of either the clinician or facility involved in this report: *

Clinician -or- Facility
First Name
*
Facility Name
*
Last Name
*
Address
Group Name City
Address State
*
City Zip
State
*
Phone
*
--
Zip
Phone
*
--


Expedited Appeal. An expedited appeal may be requested in those cases that involve an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. You or your provider should call us as soon as possible at 1-800-999-9585. Your appeal will be reviewed, a decision made, and you and your treating provider will be notified as soon as possible to accommodate your clinical condition, but not to exceed seventy-two (72) hours of our receipt of the expedited appeal request. You will be notified in writing of the determination. Additionally, USBHPC will provide the California Department of Managed Health Care ("Department") with a written statement on the disposition or pending status of the expedited appeal within three (3) days of receipt of the appeal request. If you are requesting an expedited appeal, you may also request that a separate expedited Independent Medical Review be conducted at the same time by the California Department of Managed Health Care.
California Department of Managed Health Care Notification
Grievance Process and Independent Medical Review


The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your behavioral health care service plan, you should first telephone your plan at 1-800-999-9585 or 711 for TTY (at operator request, say "1-800-999-9585") and use the 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 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-HMO-2219 or 1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department' s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

To send your grievance electronically:
Please click the "Submit" button below

To send via U.S. mail:
Please click the "Print and Mail Grievance" button below and forward printed copy to:
     Appeals & Grievances
     U.S. Behavioral Health Plan, California
     P.O. Box 30512
     Salt Lake City, UT 84130-0512
     Fax: 1-855-312-1470

      




Provider Information
If applicable, please provide the name, address and phone number of the psychiatrist or other behavioral health care provider involved in this report.

Provider Name
Provider Address
Provider City
Provider State
Provider Zip
Provider Phone - -

Expedited Appeal. An expedited appeal may be requested in those cases that involve an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. You or your provider should call us as soon as possible at 1-800-999-9585. Your appeal will be reviewed, a decision made, and you and your treating provider will be notified as soon as possible to accommodate your clinical condition, but not to exceed seventy-two (72) hours of our receipt of the expedited appeal request. You will be notified in writing of the determination. Additionally, USBHPC will provide the California Department of Managed Health Care ("Department") with a written statement on the disposition or pending status of the expedited appeal within three (3) days of receipt of the appeal request. If you are requesting an expedited appeal, you may also request that a separate expedited Independent Medical Review be conducted at the same time by the California Department of Managed Health Care.
California Department of Managed Health Care Notification
Grievance Process and Independent Medical Review


The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your behavioral health care service plan, you should first telephone your plan at 1-800-999-9585 or 711 for TTY (at operator request, say "1-800-999-9585") and use the 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 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-HMO-2219 or 1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department' s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

To send your grievance electronically:
Please click the "Submit" button below

To send via U.S. mail:
Please click the "Print and Mail Grievance" button below and forward printed copy to:
     Appeals & Grievances
     U.S. Behavioral Health Plan, California
     P.O. Box 30512
     Salt Lake City, UT 84130-0512
     Fax: 1-855-312-1470

      



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