Online Member Request, Appeal or Complaint Form

* = Mandatory Fields

Health Insurance Plan

Medi-Cal

Please fill out the form below and click “Next,” then review it to make sure it is correct. When everything is correct, click “Confirm,” and the form will be sent to us. If you have any problems filling out this form, please call our Customer Service department at the numbers below.

OneCare (HMO D-SNP)

Please fill out the form below to request a coverage decision, appeal or file a formal complaint for any part of care or service you had from CalOptima Health OneCare (HMO D-SNP). Click “Next” to make sure your information is right before you submit your form. If you need help filling out this form, please call OneCare Customer Service at 1-877-412-2734 (TTY 711).

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.

Date of Complaint:

Name of person filling out this form:

Date of Incident/Denial:

Relationship:

Please Specify:

Member first name:

Member middle initial:

Member last name:

Contact/message number:

Current home address:

City:

ZIP code:

Member ID Number:

Example: 12345678Z

Member's Date of Birth:

Do you have a denial letter signed by a doctor?

YesNo

Description of the concern or issue (Briefly describe the reason for your appeal, complaint, or request, including requests for exception of our drug coverage. Include drug name(s) or service denied, date, and details):

How have you tried to resolve this problem?

Medi-Cal

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 our Customer Service team at 1-888-587-8088 (TTY 711) toll free, 24 hours a day, 7 days a week.

Thank you for taking time to share your concerns with CalOptima Health. Please read your CalOptima Health Member Handbook for more information on your member rights, health coverage and available services.

OneCare (HMO D-SNP)

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 Customer Service Department at 1-877-412-2734.

Thank you for taking the time to share your concerns with OneCare. Please read your OneCare Member Handbook for more information on your member rights, health coverage and available services.