Employer Group 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 California, Inc. and/or Health Net Life Insurance Company (collectively, Health Net) 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:

Small Group Plans through Covered California: 1-888-926-5133, TTY 1-888-926-5180
Group Plans through Health Net: 1-800-522-0088, TTY 1-800-995-0852
Medicare Group: 1-800-275-4737

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

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? *

An Appeal A Grievance

Are you filing this for yourself or another person? *

Self Child Parent Spouse Other

If Other, please specify

Information About Member

Member ID *

Member First Name *

Member Last Name *

Mailing Address *

City *

State: *

Postal/Zip Code *

Telephone Number *

E-mail Address *

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

Best way to contact you? *

Phone Mail

OK to leave a confidential message? *

Yes No

Date of Service/Occurrence * MM/DD/YYYY

Do you have a denial letter?

Yes No

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.

Description of the concern or issue? *

A message to Heath Net of California Medicare Group members

Wellcare By Health Net will have a resolution to your complaint no later than 30 days after your submission. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

However, if we take this extension, we will notify you or your representative. We can usually help you right away or at the most within a few days. If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal", we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

If you need any help, please call us at 1-800-275-4737 (TTY: 711). From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. You can also visit Wellcare by Health Net.