Appeal Form

We will respond to you by letter or e-mailto acknowledge this request and obtain any further infomation wemay need to respond to your concern.

Your may also file a complaint by contacting the mental health access number listed on your health plan card. For questions about a formal denial or appeal you can call the National Appeals Number at (888) 426-0028.

Reason for the appeal *

Who is the Appeal for?

Member First Name *

Member Last Name *

Member Date of Birth

Member ID # (can be found on your ID card)

How should we get in touch with you?

Email (optional)

Phone Number

Work Phone Number

Cell Phone Number

Can MHN leave you a message?

(Home)

yes no

(Work)

yes no

(Cell)

yes no

Zip

Who is filing the Appeal?

Member Parent of Minor Spouse/Family Representative appointed by member

Name of Parent *

Name of Spouse/Family Member *

Name of Representative *

*This form will send your message to MHN as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with MHN through email, you accept associated risks. MHN does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI and PII, you may call (888) 426-0028.

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 1-888-426-0028 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 (1-888-466-2219) 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.