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Dental Grievance Form
Please complete all fields and read the required language below. Receipt from
you will be acknowledged within 5 calendar days, and you will be notified
of the resolution within 30 calendar days. Thank you for your cooperation.
* Required Fields
Member Name*
PacifiCare Dental ID#*
Patient Name (if applicable)
Member Address*
City*
State*
Zip Code*
Daytime Phone*
Other Phone
Email Address
Provider Information
Provider Name*
Provider Address
City
State
Zip Code
Date of First Visit*
Date Problem Occurred*
Describe your problem (Max: 2000 Characters) *
If you talked with the Provider office and/or plan personnel about this matter,
please list their name(s).
I hereby certify that this information is true and correct to the best
of my knowledge.*
Signed* (type in name)
I have read the language below and I understand it.*
Signed* (type in name)
EXPEDITED REVIEW
The Plan makes every effort to process your appeal as quickly as possible.
In some cases, you have a right to an expedited 72-hour appeal if your health
or ability to function could be seriously harmed by waiting for a standard
appeal, which may take up to 30 days. You may file an oral or written request
for a 72-hour appeal. Call, write or fax the Plan. Ask for an "expedited
review," a "72-hour review," or say, "I believe my health
could be seriously harmed by waiting for a standard review."
Call:
1-800-228-3384 (7 a.m. - 6 p.m.)
Or Write:
Grievances and Appeals, LC05-293
P.O. Box 25187
Santa Ana, CA 92799-5187
Or Fax:
(714) 513-6542
"TDD" is available by calling 1-877-735-2929.
For All California
Members
If a complaint has been sent for immediate expedited review, PacifiCare Dental
will immediately inform you in writing of your right to notify the Department
of Managed Health Care of the grievance. PacifiCare Dental will provide you
and the Department of Managed Health Care with a written statement of the
disposition of pending status of the expedited review no later than three
days from receipt of the complaint.
The following language
is required by 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 1-800-228-3384 or 1-877-735-2929
(TDD) 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-HMO-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."
PacifiCare Dental,
Attn: Grievances and Appeals, MS LC05-293
P.O. Box 25187
Santa Ana, CA 92799-5187
1-800-228-3384
Pacificare Dental products are offered by Dental Benefit Providers of California.
