(Non-Medicare Advantage members should use the "California Managed Care Member Grievance Form"
Cal MediConnect website)
This form is for your use in making suggestions, filing a formal complaint, or appeal regarding any aspect of the care or service provided to you. Your health plan is required by law to respond to your complaints or appeals, and a detailed procedure exists for resolving these situations. If you have any questions, please feel free to call the Customer Services department of your provider group and/or your health plan's Customer Service department at 1-888-816-2790 (TDD/TTY 711). Health plan customer service contact information may also be found on your health care card.
Please enter the following information. You must complete this from and Submit it for it to be completed. You can print out a copy of the form once it has been Submitted.
(*) Indicates a Required field.
If the complaint is filed by someone other than the member, please review the "Who may file an
Appeal" section on page 3 and provide the following information:
Please state the nature of the complaint, giving dates, times, persons, places, etc. involved.
If submitting by mail or fax, please date and sign below. If you are not submitting by mail or fax, please type in your name and the date and click on the submit button.
Please submit your form to CareMore. Once you Submit the form, you can print out a copy for your records. By clicking on the “Submit” button, I acknowledge that I am filing this appeal or grievance as a member or as the legal appointed representative of the member. I acknowledge that there is a penalty for providing false information.
If you wish to mail or fax a copy of this form, send your Medicare Advantage Appeal and/or Grievance Letter to your health plan at:
Health Plan Information:
CareMore Health Plan
Attn: Grievance & Appeals
12900 Park Plaza Dr. Suite 150
MS - 6151
Cerritos CA 90703
Appeals and Grievances Unit
Fax: 1-888-326-1479 or 1-562-741-4414
For Hospital / SNF Stays:
Livanta BFCC-QIO Program - Area 5 9090 Junction Dr., Suite 10 Annapolis Junction, MD 20701
CALL 1-877-599-1123 8:00am - 5:00pm. Monday through Friday
TTY 1-855-887-6668 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Information for all Medicare Advantage Members (OMB Approval No. 0938-NEW Form No. HCFA-10003-NDMC (June 2001):
You have the right to appeal.
To exercise your appeal rights, file your appeal in writing within 60 calendar days after the date of your original denial notice. Your plan can give you more time if you have a good reason for missing the deadline.
Who May File An Appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others, not previously mentioned may already be authorized under State law to act for you.
You can call us at: (1-888-816-2790) to learn how to name your authorized representative. If you have a hearing or speech impairment, please call us at TTY/ TDD (711)
If you want someone to act for you, you and your authorized representative must sign, date, and send us a statement naming that person to act for you.
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
For more information about your appeal rights, call your plan or see your Evidence of Coverage.
There Are Two Kinds of Appeals You Can File:
Standard (30 days) - You can ask for a standard appeal. Your plan must give you a decision no later than 30 days after it gets your appeal. (Your plan may extend this time by up to 14 days if you request an extension, or if it needs additional information and the extension benefits you.)
Fast (72-hour review) - You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. Your plan must decide on a fast appeal no later than 72 hours after it gets your appeal. (Your plan may extend this time by up to 14 days if you request an extension, or if your plan needs additional information and the extension benefits you.)
- If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, your plan will automatically give you a fast appeal.
- If you ask for a fast appeal without support from a doctor, your plan will decide if your health requires a fast appeal.If your plan does not give you a fast appeal, your plan will decide your appeal within 30 days.
What Do I Include With My Appeal?
You should include: your name, address, Member 10 number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why your plan should provide the service.
Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
How Do I File An Appeal?
For a Standard Appeal: You or your authorized representative should mail or deliver your written appeal to your health plan at the address indicated on the California Medicare + Choice Plan Member
Appeal & Grievance Form.
For a Fast Appeal: You or your authorized representative should contact us by telephone or fax using the plan contact information provided on the indicated on the Medicare Advantage Appeal & Grievance Form.
What Happens Next? If you appeal, your plan will review our decision. After your plan review our decision, if any of the services you requested are still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare Advantage Organization. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
Other Contact Information:
If you need information or help, call us at:
Other Resources To Help You:
Medicare Rights Center: Toll Free: 1-888-HM0-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227) TTY/TTD: 1-877-486-2048
OMS Approval No. 0938-NEW Form No. HCFA-10003-NDMC (June 2001)