Grievance Form

*Denotes Required Fields

Please refer to the Titanium Healthcare Member Rights & Privacy Notice for the Grievance Process, Grievance Rights, and Privacy. For information regarding privacy, please see the Titanium Healthcare Notice of Privacy Practices.

*NAME

*LAST NAME

*DATE OF BIRTH (DD/MM/YYYY)

*MEMBER MRN #

*MEMBER ADDRESS

*CITY

*STATE

*ZIP CODE

*PHONE NUMBER

EMAIL ADDRESS

PERSON MAKING THE COMPLAINT (if other than member) PERSON MAKING THE COMPLAINT (if other than member)

You have the right to appoint someone else to file your grievance or represent you during the grievance process. Grievances can be filed by parents, guardians, conservator, relative, or other designee, if the Member is a minor or an adult who is otherwise incapacitated. You have the right to appoint someone else to file your grievance or represent you during the grievance process. Grievances can be filed by parents, guardians, conservator, relative, or other designee, if the Member is a minor or an adult who is otherwise incapacitated.

*NAME

*RELATIONSHIP

NATURE OF COMPLAINT NATURE OF COMPLAINT

Where did this happen?

When did this happen? (If unsure, give approximate date)

*Who is the complaint against?

*What is the Issue?

PLEASE DESCRIBE WHAT HAPPENED (If issue involved more than one family member, please list them here).

Please take a moment to review this form prior to submission to ensure all information is accurate. Please take a moment to review this form prior to submission to ensure all information is accurate.

Member Rights
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 contact the phone number on the back of your ID card. 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 satis-factorily 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 dis-putes 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 http://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.
If you have any other questions or concern(s) on this matter, please call L.A. Care at 1-888-839-9909.

Medicare Members

You can contact this program with questions about your Medicare benefits at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. (You can also read or download “Medicare Rights & Protections,” found on the Medicare website at www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)

California Department of Health Care Services (DHCS) Office of the Ombudsman

You may also call the Ombudsman Office of the California Department of Health Care Services (DHCS) for help. The Ombudsman Office helps Medi-Cal beneficiaries to fully use their rights and responsibili-ties as a member of a managed care plan. To find out more, call toll-free 1-888-452-8609 Monday through Friday, 8am to 5pm PST; excluding holidays.

Additional Rights for Medi-Cal Members

State Hearing

You may ask for a State Hearing within 120 days of receiving the Notice of Appeal Resolution from L.A. Care. You may either present your case yourself, or ask someone to present your case, such as legal counsel, relative, friend, or any other person. For more about State Hearing requests, please call 1-800-952-5253 Monday through Friday, 8:00 a.m. to 5:00 p.m.; excluding holidays. For the hearing impaired TDD, please call 1-800-952-8349. To request a State Hearing in writing please send your letter to the following address:

State Hearing Division
P.O. Box 944243, MS 9-17-433
Sacramento, CA 94244-2430