TSWV CUAB DAIM NTAWV HAIS KEV HAIS KEV TSIS TXAUS SIAB THIAB THOV HAIS MUS RAU
TXHEEJ SIAB ZOG – CALIFORNIA
Thov siv daim ntawv no kom thiaj pab hais kev tsis txaus siab los yog thov hais mus rau txheej siab
zog nrog rau LIBERTY Dental Plan (LIBERTY). Koj kuj siv tau daim ntawv no kom muab ntaub ntawv
xov xwm ntxiv rau LIBERTY kom thiaj pab peb tshab xyuas koj qhov txooj xwm. Yog tias koj tau siv
xov tooj thov hais mus rau txheej siab zog, koj sau ntawv tau rau daim ntawv thov no thiab muab
xa rov qab mus rau LIBERTY. Nov yog ib yam nyob ntawm koj xaiv. Peb yuav tshab xyuas koj qhov
txooj xwm es koj tsis tas sau ntawv thov hais mus rau txheej siab zog.
TSWV CUAB TEJ XOV XWM (THOV SAU NTAWV NCAJ)
Tswv cuab lub xeem
Tswv cuab lub npe
Hnub tim
Tswv cuab qhov chaw nyob
Nroog
Xeev
Zauv cheeb tsam
Tswv cuab tus xov tooj
Tswv cuab tus naj npawb qhia saib yog leej twg (saib daim ntawv qhia
saib yog leej twg)
Qhov Chaw Ua Hauj Lwm los yog Pawg Neeg
Neeg mob lub npe
Txheeb li cas
YOG TIAS MUAJ, NEEG SAWV CEV TAM COV XOV XWM (THOV SAU NTAWV NCAJ)
Kuv tso cai rau LIBERTY Dental Plan kom cia tus neeg nram qab no sawv cev tam kuv thaum lub sij hawm hais kev txaus
Neeg sawv cev lub npe
Neeg sawv cev tus xov tooj
Tswv Cuab Kos Npe
QHOV CHAW KUAJ HNIAV/KWS KHO HNIAV TEJ XOV XWM (THOV SAU NTAWV NCAJ)
Kuv tso cai rau LIBERTY Dental Plan thov kom tau kuv cov ntaub ntawv xov xwm, suav tej ntawv ceev xwm txheej thiab
Qhov chaw kuaj hniav
tus naj npawb
Qhov chaw kuaj hniav lub npe
Hnub uas mus kuaj hniav
zaum tas los
Qhov chaw kuaj hniav qhov chaw nyob
Nroog
Xeev
Zauv cheeb tsam
Qhov chaw kuaj hniav tus xov tooj
Cov npe ntawm cov neeg ua hauj lwm ntawm qhov chaw kuaj hniav
uas paub txog qhov txooj xwm (yog tias paub)
Medicaid tej Kev Hais Mus rau Txheej Siab Zog yuav tsum yog muab fais (file) ua ntej 60 hnub txij ntawm hnub uas
sau rau ntawm koj daim Ntawv Tsis Kam Duav (Denial Letter).
Medicaid tej Kev Hais Kev Tsis Txaus Siab muab fais (file) thaum twg los tau.
Medicare tej Kev Hais Mus rau Txheej Siab Zog thiab Kev Hais Kev Tsis Txaus Siab yuav tsum yog muab fais (file) ua
ntej 90 hnub txij ntawm hnub uas sau rau ntawm koj daim Ntawv Tsis Kam Duav los yog los ntawm hnub uas muaj
xwm uas ua rau koj tsis txaus siab
Qhov Chaw Lag Luam/Tib Neeg tej Kev Hais Mus rau Txheej Siab Zog thiab Kev Hais Kev Tsis Txaus Siab yuav tsum
yog muab fais (file) ua ntej 180 hnub txij ntawm hnub uas sau rau ntawm koj daim Ntawv Tsis Kam Duav los yog los
ntawm hnub uas muaj xwm uas ua rau koj tsis txaus siab
CA G/A Form Revised 09.30.19 pg. 2
Yog tias koj xav tau kev pab sau ntawv rau daim ntawv thov no, cia li hu mus rau peb lub Chaw Pab Tswv Cuab rau
ntawm 888-703-6999 los sis TTY 877-855-8039, hnub Monday mus txog hnub Friday 8:00 teev sawv ntxov mus
txog 5:00 teev tsaus ntuj. Peb nrhiav tau ib tug neeg txhais lus rau koj, yog tias koj xav tau, es tsis tas them nqi dab
tsi. Koj los yog ib tug neeg uas koj tso cai rau muaj cai tshab xyuas koj qhov txooj xwm thaum twg los tau. Peb yuav
luam ntawv rau koj pub dawb tsis tas them nqi dab tsi.
Tswv Cuab Kos Npe
Hnub tim
THOV MUAB DAIM NTAWV UA TIAV THIAB KOS NPE RAU XA MUS RAU:
Muab Xa Mus rau:
LIBERTY Dental Plan of California
Grievances and Appeals Department
P.O. Box 26110
Santa Ana, CA 92602-26110
• Muab xa ua duab ntawv mus rau LIBERTY qhov Chaw Saib Xyuas Kev Hais Kev Tsis
Txaus Siab thiab Kev Thov Mus rau Txheej Siab Zog tus duab xov tooj rau ntawm
949-270-0109
• Hu xov tooj mus ntsib LIBERTY Dental Plan lub Chaw Pab cov Tswv Cuab rau
ntawm 888-703-6999, los sis TTY (877) 855-8039
• Siv hluav taws xob txuas rau qhov website online kom thiaj fais (file) tau qhov kev
hais kev tsis txaus siab thaum mus xyuas www.libertydentalplan.com.
• Xa email tuaj rau peb rau ntawm: GandA@libertydentalplan.com
Koj yuav txais ib tsab ntawv uas lees tias tau txais koj qhov kev hais kev tsis txaus siab los yog qhov kev thov hais mus rau
txheej siab zog ua ntej 5 hnub txij thaum LIBERTY txais tau koj qhov kev hais ntawd.
Koj yuav txais ib tsab ntawv qhia saib yuav kho koj qhov kev hais kev tsis txaus siab los yog kev hais mus rau txheej siab
zog li cas ua ntej 30 hnub txij thaum LIBERTY txais tau koj qhov kev hais ntawd.
QHOV NTSIAB LUS NTAWM KEV HAIS KEV TSIS TXAUS SIAB LOS YOG KEV THOV HAIS MUS RAU TXHEEJ SIAB ZOG
Thov sau ntawv tseg tej ntaub ntawv xov xwm dab tsi uas koj muaj hais txog koj qhov kev hais kev tsis txaus siab los yog
koj qhov kev thov hais mus rau txheej siab zog. Thov sau kom muaj txhij txhua, thiab yog tias paub, sau tej hnub, tej npe,
thiab tej kev kho hniav uas muaj thaum lub sij hawm muaj teeb meem. Yog tias koj xav tau, cia li ntxiv dua ib daim
ntawv.
Thov qhia rau peb saib koj xav kom peb kho koj qhov kev hais kev tsis txaus siab los yog koj qhov kev thov mus rau txheej
siab zog li cas.
CA G/A Form Revised 09.30.19 pg. 3
California Thawj Fab Tswj Kev Kho Mob muaj lub luag hauj lwm rau kev hloov lub txheej xwm kev npaj kho mob.
Yog hais tias koj muaj ib yam tsis txaus siab rau LIBERTY, ua ntej koj yuav tsum hu xovtooj rau LIBERTY ntawm
1-888-703-6999 thiab siv LIBERTY li txheej txheem kev tsis txaus siab ua ntej hu rau Thawj Fab Saib Xyuas. Los
ntawm kev siv txheej txheem kev foob no tsis txwv ib tus cai twg uas muaj los yog cov kev txo teeb meem uas tej
zaum siv tau rau koj. Yog koj xav tau kev pab nrog rau kev foob muaj xwm ceev, ib qho kev tsis txaus siab uas tsis
tau raug daws teeb meem txaus siab los ntawm LIBERTY, los yog kev foob ntawv tseem tsis tau raug daws hauv tshaj
30 hnub, koj hu thov kev pab tau nrog Thawj Fab Saib Xyuas. Koj kuj tseem muaj feem tau ib qhov nrog Xyuas Kev
Kho Mob Tsis Tuaj Leej Twg Tog (Independent Medical Review, IMR). Yog hais tias koj tsim nyog rau IMR, lub
txheej txheem IMR yuav muab kev luj xyuas qhov tseeb txog ntawm kev txiav txim kho mob los ntawm Health Plan
txog rau kev tsim nyog tus mob ntawm qhov kev pab los yog kev kho mob muab tawm los, kev txiav txim pov hwm
rau kev kho mob uas sim los yog tshaw mob thiab kev txiav txim nqi them rau cov kev kho mob muaj xwm ceev los
yog maj nrawm. Thawj Fab Saib Xyuas tseem muaj tus xovtooj hu dawb (1-888-HMO-2219) thiab TDD line (1-877-
688-9891) rau cov neeg tsis hnov lus thiab hais tsis tau lus. Internet web site ntawm Thawj Fab Saib Xyuas
http://www.hmohelp.ca.gov muaj cov qauv ntawv foob, IMR cov qauv ntawv thov thiab cov lus qhia hauv online.
Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) follows State and Federal civil rights
laws. LIBERTY does not unlawfully discriminate, exclude people, or treat them differently because of sex, race,
color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability,
medical condition, genetic information, marital status, gender, gender identity, or sexual orientation.
LIBERTY provides:
• Free aids and services to people with disabilities to help them
communicate better, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible
electronic formats, other formats)
• Free language services to people whose primary language is not English,
such as:
Qualified interpreters
Information written in other languages
If you need these services, please contact us between 8 a.m. to 5 p.m (PST)
by calling (888) 703-6999. Or, if you cannot hear or speak well, please call
(800) 735-2929
HOW TO FILE A GRIEVANCE
If you believe that LIBERTY has failed to provide these services or unlawfully discriminated in another way on the
basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability,
physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual
orientation, you can file a grievance with LIBERTY’s Civil Rights Coordinator. You can file a grievance by phone,
in writing, in person, or electronically:
CA G/A Form Revised 09.30.19 pg. 4
• By phone: Contact LIBERTY’s Civil Rights Coordinator, Monday through Friday, 8 a.m to 5 p.m (PST) by
calling 888-704-9833. Or if you cannot hear or speak well, please call (800) 735-2929.
• In writing: Fill out a complaint form or write a letter and send it to:
P.O. Box 26110
Santa Ana, CA 92799
• In person: Visit your doctor’s office or LIBERTY Dental Plan and say you want to file a grievance.
• Electronically: Visit LIBERTY Dental Plan website at https://www.libertydentalplan.com.
OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
You can also file a civil rights complaint with the California Department of Health Care Services, Office of Civil
Rights by phone, in writing, or electronically:
• By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711 (Telecommunications
Relay Service).
• In writing: Fill out a complaint form or send a letter to:
Michele Villados
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at http://www.dhcs.ca.gov/Pages/Language_Access.aspx.
• Electronically: Send an email to CivilRights@dhcs.ca.gov.
OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
If you believe you have been discriminated against on the basis of race, color, national origin, age, disability or sex,
you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights by phone, in writing, or electronically:
• By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800-537-7697.
• In writing: Fill out a complaint form or send a letter to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Electronically: Visit the Office for Civil Rights Complaint Portal at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
CA G/A Form Revised 09.30.19 pg. 5
IMPORTANT: You can get an interpreter at no cost to talk to your dentist or dental plan. To get an interpreter or to
request written information (in your language or in a different format, such as Braille or larger font), first call your
Dental plan’s phone number at 1-888-703-6999. Someone who speaks (your language) can help you. If you need
more help, call the HMO Help Center at 1-888-466-2219.
IMPORTANTE: Puede obtener la ayuda de un intérprete sin costo alguno para hablar con su médico o con su
plan de salud. Para obtener la ayuda de un intérprete o pedir información escrita (en su idioma o en algún
formato diferente, como Braille o tipo de letra más grande), primero llame al número de teléfono de su plan de
salud al 1-888-703-6999. Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame al
Centro de ayuda de HMO al 1-888-466-2219. (Spanish)
重要提示﹕您與您的醫生或保健計劃工作人員交談時，可獲得免費口譯服務。如需口譯員服務或索取（用
給您的語言或布萊葉盲文或大字體等不同格式提供的）書面資料，請先打電話給您的保健計劃，電話號碼
1-888-703-6999。會講（您的語言）的人士將為您提供協助。 如需更多協助，請打電話給 HMO 協助中心，
電話號碼 1-888-466-2219。(Cantonese or Mandarin)
:مﺎھ ﺔﺑﻮﺘﻜﻣ تﺎﻣﻮﻠﻌﻣ ﺐﻠﻄﻟ وأ يرﻮﻓ ﻢﺟﺮﺘﻣ ﻰﻠﻋ لﻮﺼﺤﻠﻟ .ﺔﯿﺤﺼﻟا ﻚﺘﻄﺧ وأ ﻚﺒﯿﺒط ﻊﻣ ثﺪﺤﺘﻠﻟ
ً
ﺎﻧﺎﺠﻣ يرﻮﻓ ﻢﺟﺮﺘﻣ تﺎﻣﺪﺧ ﻰﻠﻋ لﻮﺼﺤﻟا ﻚﻨﻜﻤﯾ
ﻰﻠﻋ ﺔﯿﺤﺼﻟا ﺔﻄﺨﻟا ﻒﺗﺎھ ﻢﻗﺮﺑ
ً
ﻻوأ ﻞﺼﺗا ،(ﺮﯿﺒﻛ ﻂﺨﺑ وأ ﻞﯾاﺮﺑ ﺔﻘﯾﺮط ﻞﺜﻣ ،ىﺮﺧأ ﺔﻐﯿﺼﺑ وأ ﻚﺘﻐﻠﺑ)-888-703-69991 ﺎﻣ ﺺﺨﺷ كﺪﻋﺎﺴﯿﺳ .
(ﻚﺘﻐﻟ ﺲﻔﻧ) ثﺪﺤﺘﯾةﺪﻋﺎﺴﻣ ﺰﻛﺮﻤﺑ ﻞﺼﺗا ،ةﺪﻋﺎﺴﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﺪﯾﺮﺗ ﺖﻨﻛ اذإ . HMO ﻢﻗﺮﻟا ﻰﻠﻋ-888-466-22191 (Arabic) .
ԿԱՐԵՎՈՐ ՏԵՂԵԿՈՒԹՅՈՒՆ. Դուք կարող եք խոսել Ձեր բժշկի կամ առողջապահական ծրագրի հետ՝
օգտվելով թարգմանչի ծառայություններից առանց որևէ վճարի: Թարգմանիչ ունենալու կամ գրավոր
տեղեկություն խնդրելու համար (հայերենով կամ մեկ այլ ձևաչափով, օրինակ՝ Բրայլը կամ մեծ
տառաչափը), նախ զանգահարեք առողջապահական ծրագրի հեռախոսահամարով՝ 1-888-703-6999:
Ցանկացած մեկը, ով խոսում է հայերեն, կարող է օգնել Ձեզ: Եթե Ձեզ լրացուցիչ օգնություն է
անհրաժեշտ, ապա զանգահարեք Առողջապահական օժանդակության կազմակերպության (HMO)
Օգնության կենտրոն՝ 1-888-466-2219 հեռախոսահամարով: (Armenian)
::   
    (
 ) 1-888-
703-6999  
  HMO  1-888-466-2219 (Khmer)
:ﻢﮭﻣ یاﺮﺑ ﺎﯾ یرﻮﻀﺣ ﻢﺟﺮﺘﻣ ﺖﺳاﻮﺧرد یاﺮﺑ .ﺪﯿﺷﺎﺑ ﮫﺘﺷاد یرﻮﻀﺣ ﻢﺟﺮﺘﻣ نﺎﮕﯾار رﻮﻄﺑ ﺪﯿﻧاﻮﺗ ﯽﻣ ﮫﻤﯿﺑ حﺮط ﺎﯾ ﺞﻟﺎﻌﻣ ﮏﺷﺰﭘ ﺎﺑ ﻮﮕﺘﻔﮔ یاﺮﺑ
ﺎﺑ ﺎﯾ ،دﻮﺧ نﺎﺑز ﮫﺑ) ﯽﺒﺘﮐ ترﻮﺼﺑ تﺎﻋﻼطا ﺖﻓﺎﯾرد ﯽﻨﻌﯾ دﻮﺧ حﺮط ﻦﻔﻠﺗ هرﺎﻤﺷ ﺎﺑ اﺪﺘﺑا (ﺖﺷرد پﺎﭼ ﺎﯾ ﻞﯾﺮﺑ ﺪﻨﻧﺎﻣ ﺮﮕﯾد یﺎھ ﺖﻣﺮﻓ
1-888-703-6999 ﺰﮐﺮﻣ ﺎﺑ ﺪﯾراد زﺎﯿﻧ ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﮫﺑ ﺮﮔا .ﺪھد یرﺎﯾ ار ﺎﻤﺷ ﺪﻧاﻮﺗ ﯽﻣ ،ﺪﻨﮐ ﯽﻣ ﺖﺒﺤﺻ (ار ﺎﻤﺷ نﺎﺑز) ﮫﮐ یدﺮﻓ .ﺪﯿﯾﺎﻤﻧ ﻞﺻﺎﺣ سﺎﻤﺗ
وا ما چا ﯽﻧﺎﺳر ﮏﻤﮐ(HMO) هرﺎﻤﺷ ﮫﺑ1-888-466-2219 سﺎﻤﺗ.ﺪﯿﯾﺎﻤﻧ ﻞﺻﺎﺣ (Farsi)
TSEEM CEEB: Muaj tus neeg txhais lus pub dawb rau koj kom koj tham tau nrog koj tus kws kho mob los yog
nrog lub chaw pab them nqi kho mob rau koj. Yog xav tau ib tug neeg txhais lus los yog xav tau cov ntaub ntawv
(sau ua koj yam lus los sis ua lwm yam ntawv, zoo li ua lus Braille los sis ua ntawv loj loj), xub hu rau koj lub chaw
pab them nqi kho mob tus xov tooj ntawm 1-888-703-6999. Yuav muaj ib tug neeg hais lus Hmoob pab tau koj.
Yog koj xav tau kev pab ntxiv, hu rau HMO Qhov Chaw Txais Tos Pab Neeg ntawm
1-888-466-2219. (Hmong)
중요: 의사나 건강 플랜과 대화하실 때 무료 통역 서비스를 받으실 수 있습니다. 통역을 구하시거나 문자
정보(한국어 번역본 또는 점자나 큰 글자 같이 다른 형식으로 된 정보)를 요청하시려면, 가입하신 건강
플랜에 1-888-703-6999로 먼저 전화하십시오. 한국어를 하는 사람이 도와드릴 수 있습니다. 도움이 더
필요하시면 HMO 도움 센터에 1-888-466-2219로 연락하십시오. (Korean)
CA G/A Form Revised 09.30.19 pg. 6
ВАЖНО: Вы можете бесплатно воспользоваться услугами переводчика во время обращения к врачу или в
страховой план. Чтобы запросить услуги переводчика или письменную информацию (на русском языке или
в другом формате, например, шрифтом Брайля или крупным шрифтом), позвоните в свой страховой план по
телефону 1-888-703-6999. Вам окажет помощь русскоговорящий сотрудник. Если вам нужна помощь в
других вопросах, позвоните в справочный центр Организации медицинского обеспечения (HMO) по
телефону 1-888-466-2219. (Russian)
MAHALAGA: Maaari kang kumuha ng isang tagasalin nang walang bayad upang makipag-usap sa iyong doktor o
planong pangkalusugan. Upang makakuha ng isang tagasalin o upang humiling ng nakasulat na impormasyon (sa
iyong wika o sa ibang anyo, tulad ng Braille o malalaking letra), tawagan muna ang numero ng telepono ng iyong
planong pangkalusugan sa 1-888-703-6999. Ang isang tao na nakapagsasalita ng Tagalog ay maaaring tumulong sa
iyo. Kung kailangan mo ng karagdagang tulong, tawagan ang Sentro ng Pagtulong ng HMO sa 1-888-466-2219.
(Tagalog)
LƯU Ý QUAN TRỌNG: Quý vị có thể được cấp dịch vụ thông dịch miễn phí khi đi khám tại văn phòng bác sĩ
hoặc khi cần liên lạc với chương trình bảo hiểm sức khỏe của quý vị. Để được cấp dịch vụ thông dịch hoặc yêu cầu
văn bản thông tin bằng tiếng Việt hoặc bằng một hình thức khác như chữ nổi hoặc bản in bằng chữ khổ lớn, trước
tiên hãy gọi số điện thoại của chương trình bảo hiểm sức khỏe của quý vị tại 1-888-703-6999. Sẽ có người nói tiếng
Việt giúp đỡ quý vị. Nếu quý vị cần được giúp đỡ thêm, vui lòng gọi Trung tâm Hỗ trợ HMO theo số 1-888-466-
2219. (Vietnamese)
 :               |  
    (      ,       )    , 
1-888-703-6999 ‘         |   ( )  ,   
  |       ,  1-888-466-2219 ‘ HMO Help Center (... 
)   | (Punjabi)
重要 通訳を通して医師や医療保険会社とお話しいただけます。料金はかかりません。日本語でサポートを受け
たり、日本語で書かれた情報を入手するには、あなたの医療保険会社（1-888-703-6999）までお電話ください。日
本語が話せるスタッフがお手伝いします。さらなるサポートが必要な場合は、HMO Help Center （1-888-466-
2219）までお電話ください。(Japanese)
 : ເຈົ
້
າສາມາດມີ ນາຍພາສາໂດຍບໍ
່
ຕ້ອງເສຍຄ່າເພື
່
ອເວົ
້
ານໍ າໝໍ ແຂ້ວ ຫຼື ແຜນທັນຕະແພດຂອງເຈົ
້
າ. ເພື
່
ອໄດ້ນາຍພາສາ ຫຼື
ຂໍ ຂໍ
້
ມູນທີ
່
ເປັນລາຍລັກອັກສອນ (ເປັນພາສາຂອງເຈົ
້
າ ຫຼື ຮູບແບບອື
່
ນ, ເຊັ
່
ນ ພາສານູນ (Braille) ຫຼື ຕົວຫນັງສື ທີ
່
ໃຫຍ່ ກວ່າ),
ໂທລະສັບໄປຫາແຜນທັນຕະແພດຂອງເຈົ
້
າກ່ອນ ຕາມໝາຍເລກໂທລະສັບ 1-888-703-6999. ຜູ້ ທີ
່
ເວົ
້
າພາສາ (ລາວ)
ສາມາດຊ່ວຍເຫລື ອເຈົ
້
າໄດ້. ຖ້າວ່າເຈົ
້
າຕ້ອງການຄວາມຊ່ວຍເຫລື ອເພິ
່
ມຕື
່
ມ, ໂທລະສັບໄປທີ
່
ສູນການຊ່ວຍເຫລື ອ HMO
ຕາມໝາຍເລກ 1-888-466-2219. (Lao)
  :   

  
, (Braile) ,  1-888-703-6999 
, , 
(HMO) 1-888-466-2219  (Hindi)
:






 
1-888-703-6999




 HMO
1-888-466-2219. (Thai)