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Federal laws say that you must use LIBERTY’s internal appeal process before you can request a state fair hearing. You are not losing your state fair hearing rights. After you have completed LIBERTY’s internal appeal process and you receive a decision that is not fully in your favor, you can request a state fair hearing. Information on how to request state fair hearing can be found on the Your Rights Document included with your Notice of Appeal Resolution letter.

To submit a written Grievance (Complaint) or Appeal to LIBERTY Dental Plan (LIBERTY), please complete the online form below. You can also ask your dental office for a form or print a form from our website and mail it to the address below. You can also call LIBERTY’s Member Services Department to submit a complaint or appeal over the telephone.

LIBERTY Dental Plan

Grievances and Appeals Department

P.O. Box 26110

Santa Ana, CA 92799-6110

Phone: 1-888-703-6999

Fax: 1-833-250-1814

Please provide information regarding your complaint or appeal and your desired outcome.  Your complaint or appeal will be reviewed by LIBERTY the next business day following successful submission of this Form by you. You will get a letter from us within five (5) days letting you know we received your request.  If you would like to add anything to your case, please call us right away. We will review your complaint or appeal and send you a letter of our decision within thirty (30) days from the date we received your request. You can ask for an extension if you feel more time is needed. We can also ask for an extension if it is in your best interest, but we will not take more than fourteen (14) additional days to give you a response.

If you think waiting thirty (30) days could put your health or life at risk, you can ask for a fast review. If LIBERTY finds a fast review is needed, we will give you an answer within 72 hours from the time we received your request.

If you need help with this form or if you have questions, please contact us. We are here to help!

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 1-888-703-6999 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 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website has complaint forms, IMR application forms, and instructions online.