Member GRIEVANCE FORM

Evernorth Behavioral Health of California, Inc.(Formerly Cigna Behavioral Health of California, Inc.)


How to File a Grievance

If you are concerned about the quality of service or care you have received, a benefit exclusion, or have an eligibility issue, you should contact us to file a verbal or written complaint.

If you call us to file a complaint, we will attempt to document and/or resolve your complaint over the phone.

If we are unable to resolve your complaint the day your call is received, or if we receive your complaint in the mail, we will send you a letter confirming that we received the complaint within 5 calendar days.

This letter will tell you whom to contact if you have questions or would like to submit additional information about your complaint.

We will investigate your complaint and will notify you of the outcome within 30 calendar days.

You have at least 180 calendar days to file a verbal or written complaint of your dissatisfaction.

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:

Evernorth Behavioral Health of California, Inc.
Appeals Unit
PO Box 188064
Chattanooga, TN 37422
1(877) 815-4827

If the 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 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 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 identification card.


I am submitting a grievance to Evernorth 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 Behavioral Health Member Services at 1 (800) 753-0540 or the toll-free number on your Identification Card.

Member Information

* Indicates a required field.

 
Name:
  * Last:
  * First:
  Middle Initial:


  * Subscriber ID Number:


 
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.  
  Email Address (optional):


  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.  
  Email Address (optional):

Member Grievance Information

* Indicates a required field.

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

 
  Behavioral Health Care Provider:
  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:

 

Evernorth Behavioral Health of California, Inc.
Appeals Unit
PO Box 188064
Chattanooga, TN 37422

Fax:877.815.4827

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.

Confidential, unpublished property of Evernorth Health Services. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Evernorth Health Services. Legal Disclaimer