United Concordia Dental

Grievance Form (California DHMO Members only)

This form is for California DHMO Members only.

We welcome your feedback

Grievance Process

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 1-866-357-3304 (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.

Grievance Resolution Procedure

Member's Full Name is required.
The number is the same for everyone covered on this policy.
Member ID is required.
Your Member ID is found on your Welcome Letter.
Email is required.
Confirm Your Email is required.
Must use a 10 digit number.
(optional)
Ext cannot exceed 5 characters.
Must use mm/dd/yyyy format.
Line 1 is required.
Line 2 cannot exceed 37 characters.
City is required.
State is required.
ZIP Code is required.

Dentist Information

(optional)
Dentist's Name is required.
(optional)
Dental Office ID Number is required.
(optional)
Must use a 10 digit number.
(optional)
Ext cannot exceed 5 characters.
(optional)
Line 1 is required.
Line 2 cannot exceed 37 characters.
Dentist City is required.
Dentist State is required.
Dentist ZIP Code is required.
Report Relates To is required.
Please describe your grievance...
 of 5,000 characters
How can we help you? is required.
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Non-Discrimination Notice

United Concordia Dental complies with all applicable federal civil rights laws.

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