26-601 Member Appeals and Grievances Process Overview and Reminders
Date: 05/08/26
Prompt responses are required to support timely resolution and reduce delays, repeat outreach and administrative burden
Contractual obligations and applicable regulatory requirements require you to provide timely, complete and accurate responses to requests related to member appeals and grievances, including medical records. When responses are submitted within required time frames and include all requested information, we can complete reviews efficiently and minimize follow-up requests.
Appeals and grievances
Patients who are CalViva Health members have the right to file an appeal or grievance regarding the care or services they received from us or you. Member appeals and grievances are not a delegated function and should be directed to Health Net for resolution.
Physicians, practitioners and other providers must:
- Maintain appeal and grievance forms and make them available to your patients.
Download the forms for all lines of business:
- Go to Health Net.
- Select GRIEVANCE FORM at the bottom of the page.
- Select a plan-specific form under “Go to Your Plan.”
- Ensure instructions are easy to find, including posting information in locations accessible to patients.
- Confirm that appeals or grievances submitted on behalf of a patient include a signed consent form. A signed consent form authorizes us to review and respond in accordance with regulatory and privacy requirements.
Download the consent form
- Go to CalViva Health.
- Select Member Benefits.
- Select Member Forms.
- Navigate to Authorization for Disclosure of PHI and choose the English, Spanish or Hmong Authorization Printable Form.
Where to submit appeals and grievances
If you receive a member appeal or grievance, refer to the Provider Library for the correct fax number, mailing address and the provider operations manual for the required response time frame.
Fax number or mailing address
- Go to Provider Library.
- Select the appropriate line of business.
- Open Contacts.
- Select Health Net Medi-Cal Member Appeals and Grievances Department.
Required time frames
- Go to Provider Library.
- Select the appropriate line of business.
- Open the Provider Manual.
- Navigate to Appeals, Grievances and Disputes > Member Appeals. Select Member Appeals Overview.
Medical records requests: Important for everyone as we work on cases
Per your contractual agreement, physicians, practitioners and other providers must support timely review and resolution to include:
Medical records may that be requested as part of an appeal or grievance for investigation.
Timely and complete response is required
Failure to respond by the required deadline or to submit complete medical records may result in repeat outreach, escalation or corrective action.
Your responsibilities when responding
You must respond by the due date listed in the request and:
- Submit complete, accurate and legible records for the specified patient and dates of service.
- Provide records at no cost, unless otherwise permitted by law or contract.
- Maintain records in compliance with HIPAA, California confidentiality laws and applicable policies.
- Cooperate with the appeals and grievances, quality improvement, audit, regulatory and credentialing activities.
If no medical records
If medical records do not exist or the patient was not treated during the requested time frame, notify us in your response promptly.
Need help? Contact us
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral health providers can call 844-966-0298.
This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.