GRIEVANCE FORM

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Health and Human Resource Center, Inc. DBA Aetna Resources for Living Corporate Compliance/Anti-Fraud Helpline

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GRIEVANCE FORM
(KNOX-KEENE)

In the event you become dissatisfied with any aspect of the Employee Assistance Program (EAP) services provided by Health and Human Resource Center, Inc. DBA Aetna Resources for Living, you may file a grievance by contacting the Director of Quality Improvement at:

Telephone (800) 342-8111
Fax (800) 293-1967

or you may complete and submit this form electronically:

* Denotes required field.

Tracking Number

202404280459165582

Member Name

* Last Name

* First Name

Name of Employer

Date of Incident

* Address

* City

* State

* Zip

Phone (work) include area code

Phone (work) OK to Call?

Phone (work) OK to leave message?

Phone (home) include area code

Phone (home) OK to Call?

Phone (home) OK to leave message?

Email address

* Urgency: This grievance is Routine This grievance is Urgent/Expedited

* Please describe the nature of the grievance (include names, dates of service and office location):

Reminder - Before submitting this form:

You can preview your information by reviewing your entries.
Please review your information carefully and make any changes before submitting.
If you would like a copy of the form for your records, click 'Print' before submitting.

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Health and Human Resource Center, Inc. DBA Aetna Resources for Living is committed to promptly responding to your concerns and resolving matters to your satisfaction. There is no discrimination against a member for filing a grievance.
The Director of Quality Improvement will review and investigate this matter. You will receive notification of receipt of your grievance within five days of receiving it. If the situation is clinically urgent, this letter will be sent immediately. There is no requirement that the Member participate in Health and Human Resource Center, Inc. DBA Aetna Resources for Living’s grievance process before requesting a review by the California Department of Managed Care in any case determined to involve an imminent and serious threat to the health of the patient, including but not limited to severe pain, the potential loss of life, limb, or major bodily function, or in any other case where the Department determines that an earlier review is warranted.
A letter will be sent within 30 days, or 3 days if the situation is clinically urgent, summarizing the findings of the investigation and disposition of the grievance.

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 plan at 1-800-342-8111 and use the plan’s grievance process (or locate their grievance form on their website at www.mylifevalues.com) 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 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 web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

HMO and DMO-based plans - IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at 1-800-342-8111

Your input preview:

Tracking Number:

Member Name:

Last Name:

First Name:

Name of Employer:

Date of Incident:

Address:

City:

State:

Zip:

Phone (work) include area code:

Phone (work) OK to Call:

Phone (work) OK to leave message:

Phone (home) include area code:

Phone (home) OK to Call:

Phone (home) OK to leave message:

Email address:

This grievance is:

Please describe the nature of the grievance (include names, dates of service and office location):

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