English Instructions
(En Español)
If you are unhappy with anything about your care or with Care1st Health Plan, we want to know about it. We would like to help. We also want to hear your suggestions about how we can improve our services.

If you have a complaint or grievance you may:

•	Write, Visit or Call Care1st Health Plan Grievance Coordinator at: 601 Potrero Grande Dr Monterey Park, CA 91755 Phone: 1-800-605-2556
•	Fill out a grievance form available at your provider's office.
•	Fill out and submit a grievance form that is available on this Website.  English Form Spanish Form Medical Records Release Form

Grievance Guidelines
Care1st Health Plan will work with you to resolve your grievance. Grievances will be acknowledged within five (5) days and resolved with thirty (30) days. If however, your grievance involves an immediate and serious threat to your health, including but not limited to potential loss of life, limb, or major bodily function, your grievance will be resolved with three (3) days or sooner when necessary because of your medical condition. All grievance decisions can be appealed. An explanation of the appeal process will be outlined on the Grievance Resolution Letter that will be sent to you within thirty (30) days of filing the grievance.


The California Department of Managed Healthcare
“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)-605-2556 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 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 web site http://www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.”


Independent Review of Grievances Involving
a Disputed Health Care Service
Effective January 1, 2001, patients may now request from the DMHC an independent Medical Review (IMR). Following is a copy of the IMR language and the IMR Request Form.

Application Form

You may request an independent medical review (“IMR”) of disputed health care services from the Department of Managed Health Care (“DMHC”) if you believe that health care services have been improperly denied, modified, or delayed by the Plan or one of its contracting providers. A “disputed health care service” is any health care service eligible for coverage and payment under you subscriber contract that has been denied, modified, or delayed by the Plan or one of its contracting providers, in whole or in part because the service is not medically necessary.

The IMR process is in addition to any other procedures or remedies that may be available to you. You pay no application or processing fees of any kind for IMR. You have the right to provide information in support of the request for IMR. The Plan must provide you with an IMR application form with any grievance disposition letter that denies, modifies, or delays health care services. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan regarding the disputed health care service.

Eligibility: Your application for IMR will be reviewed by the DMHC to confirm that:

(1)(A) Your provider has recommended a health care service as medically necessary, or (B) You have received urgent care or emergency services that a provider determined was medically necessary, or (C) You have been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which you seek independent review;

(2) The disputed health care service has been denied, modified, or delayed by the Plan or one of its contracting providers, based in whole or in part on a decision that the health care service is not medically necessary;

(3) You have filed a grievance with the plan or its contracting provider and the disputed decision is upheld or the grievance remains unresolved after 30 days. If your grievance requires expedited review you may bring it immediately to the Department’s attention. The DMHC may waive the requirement that you follow the Plan’s grievance process in extraordinary and compelling cases.

If your case is eligible for IMR, the dispute will be submitted to a medical specialist who will make an independent determination of whether or not the care is medically necessary. You will receive a copy of the assessment made in your case. If the IMR determines the service is medically necessary, the plan will provide the health care service.

For non-urgent cases, the IMR organization designated by the DMHC must provide its determination within 30 days of receipt of your application and supporting documents. For urgent cases involving imminent and serious threat to your health, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of your health, the IMR organization must provide its determination within 3 business days.

For more information regarding the IMR process, or to request an application form, please call the Plan’s Member Services Department at (800) 605- 2556