FORM TO FILE A STATE HEARING FROM A MANAGED CARE DENIAL

You can ask for a State Hearing by calling: 1-800-743-8525. TDD users, call

1-800-952-8349. You can also request a hearing in the following ways:

You can request a hearing ONLINE at WWW.DSS.CA.GOV

You can fill out this form and FAX it to State Hearings at 916-651-2789

You can fill out this form and EMAIL it to SCOPEOFBENEFITS@DSS.CA.GOV

(

Note: If you send it by email, please understand there is a risk that someone other than the

State Hearings Division could intercept your email. Please consider using a more secure

method of sending your request.)

You can also MAIL this State Hearing Request to:

California Department of Social Services

State Hearings Division

P.O. Box 944243, MS 9-17-37

Sacramento, CA 94244-2430

For free help filling out this form, call the legal help phone number listed on the

attached ‘Your Rights’ Notice

I do not agree with the decision about my health care. State the treatment,

drug, equipment, or service that the doctor requested. I disagree because:

________________________________________________________________

(

If you need more space, use another piece of paper and attach it to this one.)

PLEASE PROVIDE THIS INFORMATION ABOUT THE BENEFICIARY

(

This is the person who was denied medical benefits)

NAME:_______________________________________________________________________

DATE OF BIRTH: _____________________________________________________________

ADDRESS (Where you can get mail): ___________________________________________

TELEPHONE NUMBER:_________________________________________________________

Do we have your permission to communicate with you by email? [

] YES [

] NO

If Yes, what is your EMAIL ADDRESS:

Please provide your Medi-Cal BIC Card Number and /or Social Security Number if you

have one _______________________________________________________________________

Do you have Straight Medi-Cal (Fee for Service) or Managed Care? ______________________

If Managed Care, what is the name of your HEALTH PLAN: ___________________________

Revised 05.09.17

Page 2: PLEASE ANSWER EVERY QUESTION THAT APPLIES TO THE BENEFICIARY

My Doctor requested this health benefit on this date: ____________________________________

The Health Plan denied this health benefit on this date: __________________________________

I have appealed the case to the Health Plan: YES [ ] On what date? __________ NO [

The Health Plan gave an answer to the appeal: YES [ ] On what Date? ________ NO [

]

Did you ask the Health Plan for an expedited (72 Hour) appeal? [ ] YES

Did the Health Plan decide the appeal in 72 Hours? [ ] YES ] NO

[

] NO

[

I NEED THESE FOR MY HEARING (Check these Boxes if they apply to you):

I need an Expedited Hearing because my situation is urgent. My case must be

decided very quickly and I cannot wait for up to 90 days. This is what will happen without

a quick decision:

______________________________________________________________

EXPLAIN WHY YOU CANNOT WAIT UP TO 90 DAYS. If you do not explain, your

case will not be expedited and will be scheduled on the normal calendar. You can

submit a letter from your doctor or plan to show why you cannot wait.

Continued Services / Aid Paid Pending: Please continue my treatment until the

Judge decides my case. (Describe the treatment that you want to continue and say what

date the plan stopped it or is planning to stop it):

_______________________________________________________________________

I want a Free Interpreter. My language or dialect is: _________________________

I have a disability and want a reasonable accommodation to help me participate

in my hearing. The accommodation(s) I want is: ______________________________

_______________________________________________________________________

I want someone else to speak for me (represent me) at the hearing. She/he can

see my medical records that relate to this hearing and come to the hearing. The person I

have chosen to speak for me is:

Name:

Phone Number: __________________________

Address: _______________________________________________________________

My signature: _______________________________ Today’s Date: _____________________

SEND THIS FORM WITH A COPY OF THE LETTER (NOTICE OF APPEAL

RESOLUTION) YOU RECEIVED FROM YOUR PLAN IF YOU HAVE IT. (IF YOU

WANT A COPY OF THIS FORM FOR YOURSELF, COPY IT BEFORE YOU SEND IT.)