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California Grievance Form


Your Employer ID is typically the commonly-known name of the company YOU WORK FOR, but without the spaces and in lowercase. Example: xyzcorporation
Employer ID:
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Member Grievance Form
Cigna Behavioral Health of California, Inc.

How to File a Grievance

To contact us by phone, call toll free at 1.800.753.0540 or at the toll-free telephone number for mental health/substance abuse services on your Cigna HealthCare ID card.

You can also let us know about your grievance by writing to us at the address below. If you prefer, you may print and fill out the Grievance Form and mail it to:  

    Cigna Behavioral Health of California, Inc.
    Appeals Unit
    400 North Brand Boulevard
    Glendale, CA 91203

If the Cigna Behavioral Health member is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the member, as appropriate, may submit a grievance to Cigna Behavioral Health or the California Department of Managed Health Care (DMHC or the Department) as the agent of the member. In addition, a participating provider or any other person you identify may assist you or act as your agent in submitting a grievance to Cigna Behavioral Health or the DMHC.

To file your grievance online, please follow these simple steps:

  1. Complete the form below;
  2. Read the grievance information at the end of the form;
  3. Review your information and make changes if necessary;
  4. Submit the form to complete the process.

If you have any questions about this form, please call Member Services at 1-800.753.0540, or the toll-free number on your Cigna HealthCare ID card.

I am submitting a grievance to Cigna Behavioral Health of California, Inc.

Please check here if this case involves an imminent and serious threat to you or the health of the patient, including but not limited to, severe pain, the potential loss of life, limb or major bodily function. If it does, please call Cigna Behavioral Health Member Services at 1-800.753.0540 or the toll-free number on your Cigna HealthCare Identification Card.


Member Information
*Indicates a required field.

 
Name:
 

*

Last:

 

*

First:

 

*

Middle Initial:

 

*

Member ID Number:

 
Mailing Address:
 

*

Street:

 

*

City:

 

*

State:

 

*

Zip/Postal Code:


 

*

Daytime Telephone Number:

 

Evening Telephone Number:

 

Please check here if you prefer not to be contacted by phone.

 

 

Email Address (optional):


Please provide this information if you'd like to receive an email confirming receipt of your submitted grievance.


  Name of person filing grievance (if other than member)
 

Last:

   

First:

   

Middle Initial:


Patient Information
(Complete only if patient is other than member.)

 
Name:
 

Last:

 

First:

 

Middle Initial:

 

Relationship to Member

 

Member ID Number:

 
Mailing Address:
 

Street:

 

City:

 

State:

 

Zip/Postal Code:


 

Daytime Telephone Number:

 

Evening Telephone Number:

 

Please check here if you prefer not to be contacted by phone.

 

 

Email Address (optional):


Please provide this information if you'd like to receive an email confirming receipt of your submitted grievance.


Member Grievance Information
*Indicates a required field.

Please provide the name, phone number and address of the behavioral health care provider or facility referenced in this grievance.

 
 

*

Behavioral Health Care Provider:

 

*

Telephone Number:

 
Address:
 

*

Street:

 

*

City:

 

*

State:

 

*

Zip:


Briefly outline the specific details of your grievance. Identify the grievance, and when the events you describe took place. If helpful, please provide copies of all itemized bills, checks (both sides) and correspondence related to this grievance. You can send this additional information to the following address or fax number:

 

Cigna Behavioral Health of California, Inc.
Appeals Unit
400 North Brand Boulevard
Glendale, CA 91203

Fax: 860.697.7985

If this grievance involves a denial of treatment, services or supplies considered experimental for a terminal illness, and you would like to request a conference as part of the grievance process, please let us know below.


 

*


Have you sent any records, correspondence, or other concerns about this case to Cigna Behavioral Health Member Services or anyone else connected with Cigna Behavioral Health?

 

Yes No



 

If yes, please provide the contact information (including phone or fax number, if available) and the date you sent the information.



 
Cigna Behavioral Health Contact:
   

Last:

   

First:

   

Telephone/Fax Number:

   

Date(s):


Certification
I certify that this information is true and correct.


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 call your health plan office at 1-800.753.0540 or the toll-free telephone number on your Cigna identification card. Please use your health plan's grievance process before contacting the Department. Using the health plan's grievance process 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, or a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has not been resolved after 30 days, please 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 Web site, http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.


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