GRIEVANCE FORM

Submit by Mail

Click here to download the form.
Then print, fill out, and mail to:
Claremont Behavioral Services
Attn: Member Services
1050 Marina Village Pkwy
Suite 203
Alameda, CA 94501

 

Submit Online

Complete the form below then click submit to send through
Claremont’s secure server.
* Asterisk indicates required field.

Grievances must be submitted within 180 calendar days following the incident or action that is the subject of the member’s dissatisfaction.

If you need assistance in filling out this form, please call us at 1-800-834-3773.

You will be mailed an Acknowledgement of Receipt of Grievance letter within 5 calendar days of receipt of the grievance and a Grievance Resolution letter within 5 calendar days of a decision, but no later than 30 calendar days from receipt of the grievance. The Acknowledgment of Receipt of Grievance letter acknowledges that we received your complaint.

If you have any questions regarding the grievance process or your specific grievance, please contact Manager of Call Center Operations at 1-800-834-3773.

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By law, all grievances must be resolved within
thirty (30) calendar days of receipt.

IMPORTANT:
You can get an interpreter. You can get documents
read to you and some sent to you in your language.
For help, call us at 1-800-834-3773.

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 1-800-834-3773 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 website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

Please submit the completed online grievance form above or click here to download then print and mail the completed form to: Claremont Behavioral Services, Attn: Member Services, 1050 Marina Village Pkwy, Suite 203, Alameda, CA 94501.

IMR: If you believe health care services have been improperly denied, modified, or delayed by the Plan or by one of its contracting providers, you may request an Independent Medical Review (“IMR”).

Expedited Review: Expedited review of grievances is available for cases involving an imminent and serious threat to the health of the Member, including but not limited to severe pain, potential loss of life, limb or major bodily function. To request expedited review, please contact Claremont at 1-800-834-3773. When a grievance requires expedited review, the Clinical Director shall complete the review as soon as possible, including convening an emergency meeting of the Quality Management Committee if necessary. Claremont will also immediately inform the Member in writing of his/her right to notify the Department of Managed Health Care of the grievance. Claremont will provide the Member and the Department of Managed Health Care with a written statement of the disposition or pending status of the grievance no later than three (3) calendar days from receipt of the grievance.