Online Member Request, Appeal Or Complaint Form

Online Member Request, Appeal or Complaint Form
Please fill out the form below to request a coverage decision, appeal or to file a formal complaint for any part of care or service you had from OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan). Click “Next” to make sure your information is right before you submit your form. If you have any problems filling out this form, please call OneCare Connect Customer Service department at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929.

If you wish to have someone represent you other than your doctor, you must submit an Appointment of Representative Form or a legal document authorizing a representative to act on your behalf.

* = Mandatory Fields
Date of Complaint: Tuesday, December 11, 2018
 
*Date of Incident/Denial: / /  
 
 
 
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Please take some time to review this form to make any changes or add more information. If you have any problems filling out this form, please call OneCare Connect Customer Service department at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929.
Thank you for taking time to share your concerns with OneCare Connect. Please read your OneCare Connect Member Handbook for more information on your member rights, health coverage and available services.

To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H8016_19MM027_M Accepted (09/25/18)

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, co-pays, and restrictions may apply. For more information, call OneCare Connect Customer Service or read the OneCare Connect Member Handbook. Benefits and/or copayments may change on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. Other Pharmacies/Physicians/Providers are available in our network. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. OneCare Connect complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. You can get this information for free in other languages. Call toll-free 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. The call is free.

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