Please select Complaint in order to express your dissatisfaction with the service, system, or clinical care provided by MHN or its network providers.

Please select Appeal to request payment for services that have previously been denied in writing by MHN.

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.

Please specify: Complaint Appeal
     
Reason for the complaint or appeal:

Who is Complaint or Appeal for?
Members First Name:
Members Last Name:
Members Date of Birth: format: (mm/dd/yyyy)
Member Number:
 
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 (Work) yes (Cell) yes
no no no
Address :
City: , CA Zip:
 
Who is filing Complaint or Appeal?
  member  
  Parent of a minor:
  Spouse/family:
  Representative appointed by member:
   

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 (888) 426-0028 and use your health plans 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.