Complaint & Grievance Form
Please provide as much detail as possible, including any supporting documentation. For assistance in completing this form, or if you have any questions, please call: 888-632-3676.
Para ayuda a llenar esta forma, o si usted tiene cualquier pregunta, por favor llame: 888-632-3676
First Dental Health (the “Plan”), the parent company of New Dental Choice (NDC), will take the following steps to resolve a Complaint/ Grievance filed:
- Upon receipt of the Complaint / Grievance, an investigation will commence with an initial call to the provider's office (within 48 business hours of receipt by New Dental Choice)
- If not resolved within five (5) days, an Acknowledgement of Complaint letter will be sent via US First-Class Mail or Email
- Once a satisfactory outcome has been reached and the Complaint /Grievance is considered resolved by all parties, a Resolution letter is sent to the member either by US First-Class Mail or Email within thirty (30) calendar days of the Acknowledgment of Complaint letter
Thank you for taking the time to express your opinions and concerns. Your feedback is important to us and is viewed as an important tool in providing a quality dental discount program. If you have any questions, contact us at 1-888-623-3676, Monday to Friday 8:00am to 5:00pm PST or by email at firstname.lastname@example.org.
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 1-888-632-3676 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 eligibile 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.
Date of Service
Complaint and Grievance Comment