To submit a written Grievance, please use the link below to print and mail to LIBERTY Dental Plan, or complete the online form below.
GRIEVANCE FORM (English)
GRIEVANCE FORM (Spanish)
Please complete the Grievance Form with all related information. LIBERTY considers a complaint and grievance as the same. Please provide information regarding your complaint and your desired or proposed resolution to the complaint. Your complaint will be considered by LIBERTY the next business day following successful submission of this Form by you. LIBERTY will send a written acknowledgement letter within five (5) days of receipt of this Form. LIBERTY will review your complaint and send you written notice of our determination within thirty (30) days of receipt of this Form. So that we may properly research and resolve this matter, a copy of your completed Grievance Form may be forwarded to the dentist(s) who provided treatment.
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 1-888-703-6999 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 remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for 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 web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.