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MEMBER - GRIEVANCE FORM

Live life. Smiling.

Contact Phone:1-800-937-3400

Mon-Fri 8am-5pm PST

THE KNOX-KEENE HEALTH CARE SERVICE PLAN ACT OF 1975

PrimeCare Dental Plan of California is subject to the requirements of Chapter 2.2 of Division 2 of California Health and Safety Code and Subchapter 5.5 of Chapter 3 of Title 28 of the California Administrative Code. Any provision required to be in the Subscriber Agreement binds the Plan whether or not included in your subscriber agreement, i.e. the Plan Contract.

Alternative remedies available to you include the following:

  • The mailing of a completed complaint form to PrimeCare Dental Plan. Complaints may also be made by telephone to the numbers set forth on the front of this Complaint Form. In addition, complaints may be submitted online by completing the grievance form set forth below
  • 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 (909) 483-8310 or 1-800-937-3400 and use your health plan 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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.
  • A request to the Plan for voluntary mediation with each party sharing equally in the costs of mediation. This alternative may be exercised at any time.
  • After completing the grievance or participating in the process for at least 30 days, the grievance or complaint may be submitted to the Department of Managed Health Care for review.
  • PrimeCare Dental Plan will expedite review of grievances for cases involving an imminent and serious threat to the health of the patient including but not limited to, severe pain, potential loss of life, limb, or major bodily function. When PrimeCare Dental Plan has notice of a case requiring expedited review, PrimeCare Dental will immediately inform enrollees in writing of their right to notify the Department of Managed Care. When a grievance is expedited for review, PrimeCare Dental will provide the enrollee and the Department of Managed Care with a written statement on the disposition or pending status of the grievance within three days from receipt of the grievance.
  • Failure to engage in the grievance process does not preclude you from using any other remedy provided by law, e.g. a civil suit.
  • Remember, we are as close as your telephone. Your dental health and welfare is important to us.

Dental Service Grievance Form

A copy of the formal Grievance Procedure for the PrimeCare Dental Plan is available for review by contacting a Member Service Representative. You may telephone your complaint by calling a Member Service Coordinator at 1-800-937-3400, or you can fax it to (909) 483-5351, or by writing to:

ICON
PrimeCare Dental Plan
10700 Civic Center Dr., Suite 100-A
Rancho Cucamonga, CA 91730

For our limited English proficient members, our LAP (Language Assistance Program) allows you to access free interpretation services in your native language at 1-800-937-3400. Upon receipt of this complaint, we will acknowledge your grievance in writing and begin an investigation into the circumstances of your complaint. You will be advised, in writing, as to the disposition of this complaint within thirty (30) days of receipt of this complaint by PrimeCare Dental Plan. If you are not satisfied with the disposition of the complaint, you are entitled to exercise any of the alternative remedies above, in Exhibit W-2.

Grievance Form

By checking the box, I am acknowledging all the terms and conditions listed above and
    have provided all information to the best of my knowledge.
By checking the box, I am acknowledging all the terms and conditions listed above and have provided all information to the best of my knowledge.