California Member Grievance Form

Cigna HealthCare of California, Inc.

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

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

If you have any questions about this form, please call Member Services at 1.800.244.6224, or the toll-free number on your Cigna HealthCare ID card.

I am submitting a grievance to Cigna HealthCare of California, Inc. (Cigna HealthCare).

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 HealthCare Member Services at 1.800.244.6224 The hearing impaired may call the California Relay Service at 1.800.735.2929 or 1.888.877.5378. or the toll-free number on your Cigna HealthCare Identification Card.

Subscriber/Patient Information

* Indicates a required field.

	Subscriber Name:
	*	Last:
	*	First:
		Middle Initial:

	*	Subscriber Date of Birth:
			MM	DD	YYYY

Subscriber ID Number:

	Subscriber Mailing Address:
	*	Street:
	*	City:
	*	State:
	*	Zip/Postal Code:

*	Daytime Telephone Number:	Ex. 9999999999
	Evening Telephone Number:	Ex. 9999999999
	Please check here if you prefer not to be contacted by phone.

	Name of person filing grievance (if other than subscriber)
		Last:
		First:
		Middle Initial:

Patient Information

(Complete only if patient is other than subscriber)

	Patient Name:
		Last:
		First:
		Middle Initial:
		Relationship to Subscriber:
		Member ID Number:

	Patient Mailing Address:
		Street:
		City:
		State:
		Zip/Postal Code:

		Daytime Telephone Number:	Ex. 9999999999
		Evening Telephone Number:	Ex. 9999999999
		Please check here if you prefer not to be contacted by phone.

Physician or Medical Group Information

* Indicates a required field.

Please provide the name, phone number and address of any physician or medical group referenced in this grievance.


		Physician/Medical Group Name:
		Telephone Number:	Ex. 9999999999

	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 HealthCare National Appeals
PO Box 188011
Chattanooga, TN 37422

Fax 1.866.254.9406

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 HealthCare Member Services or anyone else connected with Cigna HealthCare?

Yes No
If yes, please provide the contact information (including phone or fax number, if available) and the date you sent the information.
Cigna HealthCare Contact:
	Last:
	First:
	Telephone/Fax Number:	Ex. 9999999999
	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 telephone your health plan at (1-800-244 6224), (Dial 711 (TYY) for the hearing and speech impaired) 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.