YOUR RIGHTS  
UNDER MEDI-CAL MANAGED CARE  
IF YOU DO NOT AGREE WITH THE DECISION MADE FOR YOUR MEDICAL  
TREATMENT, YOU CAN FILE AN APPEAL. THIS APPEAL IS FILED WITH YOUR  
HEALTH PLAN.  
HOW TO FILE AN APPEAL  
You have 60 days from the date of this “Notice of Action” letter to file an appeal. But, if  
you are currently getting treatment and you want to continue getting treatment,  
you must ask for an appeal within 10 days from the date this letter was postmarked  
or delivered to you, OR before the date your health plan says services will stop. You  
must say that you want to keep getting treatment when you file the appeal.  
You can file an appeal by phone, in writing, or electronically:  
•
By phone: Contact LIBERTY Dental Plan’s Member Services Department  
between 8:00 am to 5:00 pm by calling 888-703-6999. Or, if you cannot hear or  
speak well, please call TTY: 800-735-2929.  
•
In writing: Fill out an appeal form or write a letter and send it to:  
LIBERTY Dental Plan of California  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
Your doctor’s office will have appeal forms available. Your health plan can also  
send a form to you.  
•
Electronically: Visit your health plan’s website. Go to www.libertydentalplan.com.  
You may file an appeal yourself. Or, you can have a relative, friend, advocate, doctor,  
or attorney file the appeal for you. You can send in any type of information you want  
your health plan to review. A doctor who is different from the doctor who made the first  
decision will look at your appeal.  
Your health plan has 30 days to give you an answer. At that time, you will get a “Notice  
of Appeal Resolution” letter. This letter will tell you what the health plan has decided. If  
you do not get a letter within 30 days, you can:  
•
Ask for an “Independent Medical Review” (IMR) and an outside reviewer that  
is not related to the health plan will review your case.  
•
Ask for a “State Hearing” and a judge will review your case  
Please read the section below for instructions on how to ask for an IMR or State  
Hearing.  
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EXPEDITED APPEALS  
If you think waiting 30 days will hurt your health, you might be able to get an answer  
within 72 hours. When filing your appeal, say why waiting will hurt your health. Make  
sure you ask for an “expedited appeal.”  
IF YOU DO NOT AGREE WITH THE APPEAL DECISION  
If you filed an appeal and received a “Notice of Appeal Resolution” letter telling you that  
your health plan will still not provide the services, or you never received a letter telling  
you of the decision and it has been past 30 days, you can:  
•
Ask for an “Independent Medical Review” (IMR) and an outside reviewer that  
is not related to the health plan will review your case  
•
Ask for a “State Hearing” and a judge will review your case  
You can ask for both an IMR and State Hearing at the same time. You can also ask  
for one before the other to see if it will resolve your problem first. For example, if you  
ask for an IMR first, but do not agree with the decision, you can still ask for a State  
Hearing later. However, if you ask for a State Hearing first, but the hearing has already  
taken place, you cannot ask for an IMR. In this case, the State Hearing has the final  
say.  
You will not have to pay for an IMR or State Hearing.  
INDEPENDENT MEDICAL REVIEW (IMR)  
If you want an IMR, you must first file an appeal with your health plan. If you do not  
hear from your health plan within 30 days, or if you are unhappy with your health plan’s  
decision, then you may then request an IMR. You must ask for an IMR within 180 days  
from the date of the “Notice of Appeal Resolution” letter.  
You may be able to get an IMR right away without filing an appeal first. This is in  
cases where your health is in immediate danger or the request was denied  
because treatment is considered experimental or investigational.  
The paragraph below will provide you with information on how to request an IMR. Note  
that the term “grievance” is talking about both “complaints” and “appeals.”  
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  
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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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing  
and speech impaired. The Department’s Internet Website  
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms, and  
instructions online.  
STATE HEARING  
If you want a State Hearing, you must ask for one within 120 days from the date of the  
“Notice of Appeal Resolution” letter. You can ask for a State Hearing by phone or in  
writing:  
•
•
By phone: Call 1-800-952-5253. This number can be very busy. You may get a  
message to call back later. If you cannot speak or hear well, please call  
TTY/TDD 1-800-952-8349.  
In writing: Fill out a State Hearing form or send a letter to:  
California Department of Social Services  
State Hearings Division  
P.O. Box 944243, Mail Station 9-17-37  
Sacramento, CA 94244-2430  
Be sure to include your name, address, telephone number, Social Security  
Number, and the reason you want a State Hearing. If someone is helping you  
ask for a State Hearing, add their name, address, and telephone number to the  
form or letter. If you need an interpreter, tell us what language you speak. You  
will not have to pay for an interpreter. We will get you one.  
After you ask for a State Hearing, it could take up to 90 days to decide your case and  
send you an answer. If you think waiting that long will hurt your health, you might be  
able to get an answer within 3 working days. Ask your doctor or health plan to write a  
letter for you. The letter must explain in detail how waiting for up to 90 days for your  
case to be decided will seriously harm your life, your health, or your ability to attain,  
maintain, or regain maximum function. Then, make sure you ask for an “expedited  
hearing” and provide the letter with your request for a hearing.  
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You may speak at the State Hearing yourself. Or, someone like a relative, friend,  
advocate, doctor, or attorney can speak for you. If you want another person to speak  
for you, then you must tell the State Hearing office that the person is allowed to speak  
on your behalf. This person is called an “authorized representative.”  
LEGAL HELP  
You may be able to get free legal help. Call the  
Entity Name  
Telephone  
County Served  
Alpine, Amador, Butt,  
Calaveras, Colusa, El  
Dorado, Glenn, Inyo, Mono,  
Nevada, Placer, Plumas,  
Sacramento, San Joaquin,  
Legal Services of Northern California  
(888) 354-4474 Sierra, Sutter, Tehama, Yuba  
Greater Bakersfield Legal Assistance, Inc. (888) 292-4252 Kern  
Fresno, Kings, Madera,  
Mariposa, Stanislaus, Tulare,  
(559) 570-1200 Tuolumne  
Central California Legal Services, Inc.  
California Rural Legal Assistance, Inc.  
Legal Aid Foundation of Los Angeles  
(760) 353-0220 Imperial  
(800) 399-4529 Los Angeles  
Legal Aid Society of San Diego  
(877) 534-2524 San Diego  
You may also call the local Legal Aid Society in your county at 1-888-804-3536.  
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