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:
- 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) 753-0540, or the toll-free number on your identification
card.
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