Grievance Form

MediExcel Health Plan is committed to meeting the needs of our members. Our Member Services staff is available to answer questions and assist you with getting the quality care you need. If you have a concern with MediExcel Health Plan, you have the right to file a complaint. A complaint is also referred to as a grievance. Here are some examples of when you can file a complaint with MediExcel Health Plan:

• You have been denied a service, treatment, or medicine.
• You have been denied a referral.
• MediExcel Health Plan cancels your health benefits.
• MediExcel Health Plan does not reimburse you for a covered service that you paid for and received.
• MediExcel Health Plan does not pay for emergency room care you needed.
• You are unable to obtain an appointment as soon as you need it.
• You feel you received poor care or service.

When filing your complaint or grievance with MediExcel Health Plan Member Services, please keep the following in mind:

• If your concern is urgent, MediExcel Health Plan must give you a resolution within 3 days. An urgent problem is an immediate and serious threat to your health.
• If your concern is not urgent, MediExcel Health Plan must give you a resolution within 30 days.
• You must file your complaint within 6 months after the incident or action that is the cause of your concern with MediExcel Health Plan.

Please remember to add one or more of the following to the Subject Case on the form below when filing your complaint or grievance:

• Grievance expedited processing (pain or immediate danger to member's health)
• Complaint about access to care (including waiting times for appointments)
• Coverage dispute
• Dispute involving medical necessity
• Complaint about experimental/investigational treatment
• Complaint about the quality of care
• Compaint about quality of service
• Other issue (s)

California law requires that we include the following statements:

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; in the U.S., call (855) 633-4392. In Baja California, México, call (664) 633-8555, 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 an 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.

Please note that grievances involving rescissions, cancellations and nonrenewal grievances are treated as expedited grievances and the enrollee does not need to submit a grievance first to the health plan. If you believe your health coverage has been, or will be improperly cancelled, rescinded, or not renewed, you may also call the Department of Managed Healthcare for assistance.

PLEASE REVIEW INFORMATION BEFORE PRESSING SEND

Name of complainant*

E-mail

Telephone number*

Member ID number*

Subject*

Grievance (please write)*

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