Learn More: Contact Us Grievance Form Home page /Legal /Grievance Form To report a concern regarding Western Health Advantage, our network providers, or if you are unhappy with the care or service you received, please contact Member Services. We will try to resolve any problem you might have over the phone. Member Services can also assist you with submitting a written grievance. You can also start the grievance process by filling out the secure online form below or by downloading the Grievance Form [Presentacion de Quejas]. Please describe the situation fully, including the specific details of the problem such as where and when it happened, and what you believe Western Health Advantage can do to resolve the concern. When you are finished, click the "Submit and Review" button at the bottom of the page. You may review your grievance prior to submitting it to the Plan. If you believe that your membership has been or will be improperly cancelled, rescinded, or not renewed, learn more about filing a grievance. Do you have a grievance about your dental, vision, acupuncture, or mental health care services? Contact our Plan partners for information regarding how to lodge a grievance or appeal. If after seeking assistance from our Plan partners you are still unsatisfied, contact Member Services for further assistance. If this is an emergency please call 9-1-1. For immediate assistance or if waiting for a response could seriously jeopardize your health, please contact Member Services. Importante: Puede leer este documento? Si no, nosotros le podemos ayudar a leerlo. Además, usted puede recibir este documento escrito en español. Para obtener ayuda gratuita, llame ahora mismo a Western Health Advantage al 916.563.2250 o gratis al 888.563.2250, lunes a viernes de 8 a.m. a 6 p.m. Haga clic aquí para obtener más información sobre cómo presentar una queja o apelación. Grievance Form MEMBER ID FIRST NAME LAST NAME STREET ADDRESS LINE 1 STREET ADDRESS LINE 2 CITY STATE Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE DAYTIME PHONE NUMBER EVENING PHONE NUMBER EMAIL ADDRESS CONCERN 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 1-888-563-2250 (TTY/TDD 1-888-877-5378) and use your health plan’s grievance process before contacting the department. If you believe your health coverage has been, or will be improperly cancelled, rescinded, or not renewed, you may also call the Department for assistance. 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 http://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online. For your protection, this form is secured using SSL (Secure Socket Layer) technology. If you prefer to speak to a customer service representative over the phone about your grievance, please contact Member Services. Member Resources Getting Started Find a Doctor Mobile App Register for MyWHA Quick Help Contact Us FAQs Send us Feedback Shop Plans About About WHA Blog Giving Back Careers Other Sites Members Broker CalPERS Employers Providers GRIEVANCE FORM Legal Privacy Terms of Use Non-Discrimination العربية 中文 日本語 Hmong 한국어 русский Tagalog այերեն ارسی Khmer Lao Español Tiếng Việt ภาษาไทย हिंदी ខ្មែរ Copyright © 2021 Western Health Advantage. All Rights Reserved. For the latest Coronavirus (COVID-19), click here: getting care, testing and vaccines