Every health care service plan shall establish a grievance
system pursuant to the requirements of Section
1368 of the Act.
(a) The grievance system shall be established
in writing and provide for procedures that will receive, review and resolve
grievances within 30 calendar days of receipt by the plan, or any provider or
entity with delegated authority to administer and resolve the plan's grievance
system. The following definitions shall apply with respect to the regulations
relating to grievance systems:
(1) "Grievance"
means a written or oral expression of dissatisfaction regarding the plan and/or
provider, including quality of care concerns, and shall include a complaint,
dispute, request for reconsideration or appeal made by an enrollee or the
enrollee's representative. Where the plan is unable to distinguish between a
grievance and an inquiry, it shall be considered a grievance.
(2) "Complaint" is the same as
"grievance."
(3) "Complainant" is
the same as "grievant," and means the person who filed the grievance including
the enrollee, a representative designated by the enrollee, or other individual
with authority to act on behalf of the enrollee.
(4) "Resolved" means that the grievance has
reached a final conclusion with respect to the enrollee's submitted grievance,
and there are no pending enrollee appeals within the plan's grievance system,
including entities with delegated authority.
(A) If the plan has multiple internal levels
of grievance resolution or appeal, all levels must be completed within 30
calendar days of the plan's receipt of the grievance.
(B) Grievances that are not resolved within
30 calendar days, or grievances referred to the Department's complaint or
independent medical review system, shall be reported as "pending" grievances
pursuant to subsection (f) below. Grievances referred to external review
processes, such as reviews of Medicare Managed Care determinations pursuant to
42 C.F.R. Part
422 , or the Medi-Cal Fair Hearing process, shall also be
reported pursuant to subsection (f) until the review and any required action by
the plan resulting from the review is completed.
(b) The plan's grievance system shall include
the following:
(1) An officer of the plan
shall be designated as having primary responsibility for the plan's grievance
system whether administered directly by the plan or delegated to another
entity. The officer shall continuously review the operation of the grievance
system to identify any emergent patterns of grievances. The system shall
include the reporting procedures in order to improve plan policies and
procedures.
(2) Each plan's
obligation for notifying subscribers and enrollees about the plan's grievance
system shall include information on the plan's procedures for filing and
resolving grievances, and the telephone number and address for presenting a
grievance. The notice shall also include information regarding the Department's
review process, the independent medical review system, and the Department's
toll-free telephone number and website address.
(3) The grievance system shall address the
linguistic and cultural needs of its enrollee population as well as the needs
of enrollees with disabilities. The system shall ensure all enrollees have
access to and can fully participate in the grievance system by providing
assistance for those with limited English proficiency or with a visual or other
communicative impairment. Such assistance shall include, but is not limited to,
translations of grievance procedures, forms, and plan responses to grievances,
as well as access to interpreters, telephone relay systems and other devices
that aid disabled individuals to communicate. Plans shall develop and file with
the Department a policy describing how they ensure that their grievance system
complies with this subsection within 90 days of the effective date of this
regulation.
(4) The plan shall
maintain a toll-free number, or a local telephone number in each service area,
for the filing of grievances.
(5) A
written record shall be made for each grievance received by the plan, including
the date received, the plan representative recording the grievance, a summary
or other document describing the grievance, and its disposition. The written
record of grievances shall be reviewed periodically by the governing body of
the plan, the public policy body created pursuant to section
1300.69, and by an officer of the
plan or his designee. This review shall be thoroughly documented.
(6) The plan grievance system shall ensure
that assistance in filing grievances shall be provided at each location where
grievances may be submitted. A "patient advocate" or ombudsperson may be
used.
(7) Grievance forms and a
description of the grievance procedure shall be readily available at each
facility of the plan, on the plan's website, and from each contracting
provider's office or facility. Grievance forms shall be provided promptly upon
request.
(8) The plan shall assure
that there is no discrimination against an enrollee or subscriber (including
cancellation of the contract) on the grounds that the complainant filed a
grievance.
(9) The grievance system
shall allow enrollees to file grievances for at least 180 calendar days
following any incident or action that is the subject of the enrollee's
dissatisfaction.
(c)
Through periodic medical surveys under Section
1380 of the Act, the Department
shall periodically review the plan's grievance system, including the records of
grievances received by the plan, and assess the effectiveness of the plan
policies and actions taken in response to grievances.
(d) The plan shall respond to grievances as
follows:
(1) A grievance system shall provide
for a written acknowledgment within five (5) calendar days of receipt, except
as noted in subsection (d)(8). The acknowledgment will advise the complainant
that the grievance has been received, the date of receipt, and provide the name
of the plan representative, telephone number and address of the plan
representative who may be contacted about the grievance.
(2) The grievance system shall provide for a
prompt review of grievances by the management or supervisory staff responsible
for the services or operations which are the subject of the
grievance.
(3) The plan's
resolution, containing a written response to the grievance shall be sent to the
complainant within thirty (30) calendar days of receipt, except as noted in
subsection (d)(8). The written response shall contain a clear and concise
explanation of the plan's decision. Nothing in this regulation requires a plan
to disclose information to the grievant that is otherwise confidential or
privileged by law.
(4) For
grievances involving delay, modification or denial of services based on a
determination in whole or in part that the service is not medically necessary,
the plan shall include in its written response, the reasons for its
determination. The response shall clearly state the criteria, clinical
guidelines or medical policies used in reaching the determination. The plan's
response shall also advise the enrollee that the determination may be
considered by the Department's independent medical review system. The response
shall include an application for independent medical review and instructions,
including the Department's toll-free telephone number for further information
and an envelope addressed to the Department of Managed Health Care, HMO Help
Center, 980 Ninth Street, 5th Floor, Sacramento, CA 95814.
(5) Plan responses to grievances involving a
determination that the requested service is not a covered benefit shall specify
the provision in the contract, evidence of coverage or member handbook that
excludes the service. The response shall either identify the document and page
where the provision is found, direct the grievant to the applicable section of
the contract containing the provision, or provide a copy of the provision and
explain in clear concise language how the exclusion applied to the specific
health care service or benefit requested by the enrollee. In addition to the
notice set forth at Section
1368.02(b) of the
Act, the response shall also include a notice that if the enrollee believes the
decision was denied on the grounds that it was not medically necessary, the
Department should be contacted to determine whether the decision is eligible
for an independent medical review.
(6) Copies of grievances and responses shall
be maintained by the Plan for five years, and shall include a copy of all
medical records, documents, evidence of coverage and other relevant information
upon which the plan relied in reaching its decision.
(7) The Department's telephone number, the
California Relay Service's telephone numbers, the plan's telephone number and
the Department's Internet address shall be displayed in all of the plan's
acknowledgments and responses to grievances in 12-point boldface type with the
statement contained in subsection (b) of Section
1368.02 of the Act.
(8) Grievances received over the telephone
that are not coverage disputes, disputed health care services involving medical
necessity or experimental or investigational treatment, and that are resolved
by the close of the next business day, are exempt from the requirement to send
a written acknowledgment and response. The plan shall maintain a log of all
such grievances containing the date of the call, the name of the complainant,
member identification number, nature of the grievance, nature of resolution,
and the plan representative's name who took the call and resolved the
grievance. The information contained in this log shall be periodically reviewed
by the plan as set forth in subsection (b).
(e) The plan's grievance system shall track
and monitor grievances received by the plan, or any entity with delegated
authority to receive or respond to grievances. The system shall:
(1) Monitor the number of grievances received
and resolved; whether the grievance was resolved in favor of the enrollee or
plan; and the number of grievances pending over 30 calendar days. The system
shall track grievances under categories of Commercial, Medicare and
Medi-Cal/other contracts. The system shall indicate whether an enrollee
grievance is pending at:
(1) the plan's
internal grievance system;
(2) the
Department's consumer complaint process;
(3) the Department's Independent Medical
Review system;
(4) an action filed
or before a trial or appellate court; or
(5) other dispute resolution process.
Additionally, the system shall indicate whether an enrollee grievance has been
submitted to:
(1) the Medicare review and
appeal system;
(2) the Medi-Cal fair
hearing process; or
(3)
arbitration.
(2) The system shall be able to indicate the
total number of grievances received, pending and resolved in favor of the
enrollee at all levels of grievance review and to describe the issue or issues
raised in grievances as (1) coverage disputes, (2) disputes involving medical
necessity,
(3) complaints about the
quality of care and
(4) complaints
about access to care (including complaints about the waiting time for
appointments), and
(5) complaints
about the quality of service, and
(6) other issues.
(f) Quarterly Reports
(1) All plans shall submit a quarterly report
to the Department describing grievances that were or are pending and unresolved
for 30 days or more. The report shall be prepared for the quarters ending March
31st, June 30th, September 30th and December 31st of each calendar year. The
report shall also contain the number of grievances referred to external review
processes, such as reconsiderations of Medicare Managed Care determinations
pursuant to 42 C.F.R. Part
422, the Medi-Cal fair hearing process, the
Department's complaint or Independent Medical Review system, or other external
dispute resolution systems, known to the plan as of the last day of each
quarter.
(2) The quarterly report
shall include:
(A) The licensee's name,
quarter and date of the report;
(B)
The total number of grievances filed by enrollees that were or are pending and
unresolved for more than 30 calendar days at any time during the quarter under
the categories of Commercial, Medicare, and Medi-Cal/other products offered by
the plan;
(C) A brief explanation
of why the grievance was not resolved in 30 days, and indicate whether the
grievance was or is pending at:
(1) the
plan's internal grievance system;
(2) the Department's consumer complaint
process;
(3) the Department's
Independent Medical Review system;
(4) court; or
(5) other dispute resolution processes.
Alternatively, the plan shall indicate whether the grievance was or is
submitted to:
(1) the Medicare review and
appeal system;
(2) the Medi-Cal fair
hearing process; or
(3)
arbitration.
(D) The nature of the unresolved grievances
as (1) coverage disputes; (2) disputes involving medical necessity; (3)
complaints about the quality of care; (4) complaints about access to care
(including complaints about the waiting time for appointments); (5) complaints
about the quality of service; and (6) other issues. All issues reasonably
described in the grievance shall be separately categorized.
(E) The quarterly report shall not contain
personal or confidential information with respect to any
enrollee.
(3) The
quarterly report shall be verified by an officer authorized to act on behalf of
the plan. The report shall be submitted in writing or through electronic filing
to the Department's Sacramento Office to the attention of the Filing Clerk no
later than 30 days after each quarter. The quarterly report shall not be filed
as an amendment to the plan application.
(4) The quarterly report shall be filed in
the format specified in subsection (i).
(g) An enrollee may submit a grievance to the
Department. The Department shall notify the plan, and within five (5) calendar
days after notification, the plan shall provide the following information to
the Department:
(1) A written response to the
issues raised by the grievance.
(2)
A copy of the plan's original response sent to the enrollee regarding the
grievance.
(3) A complete and
legible copy of all medical records related to the grievance. The plan shall
inform the Department if medical records were not used by the plan in resolving
the grievance.
(4) A copy of the
cover page and all relevant pages of the enrollee's Evidence of Coverage (EOC),
with the specific applicable sections underlined. If the plan relied solely on
the EOC, the plan shall notify the Department of that fact.
(5) All other information used by the plan or
relevant to the resolution of the grievance.
(6) The Department may request additional
information or medical records from the plan. Within five (5) calendar days of
receipt of the Department's request, the plan shall forward information and
records that are maintained by the plan or any contracting provider. If
requested information cannot be timely forwarded to the Department, the plan's
response will describe the actions being taken to obtain the information or
records and when receipt is expected.
(h) Nothing in this section shall preclude an
enrollee from seeking assistance directly from the Department in cases
involving an imminent or serious threat to the health of the enrollee or where
the Department determines an earlier review is warranted. In such cases, the
Department may require the plan and contracting providers to expedite the
delivery of information.
The Department may consider the failure of a plan to timely
provide the requested information as evidence in favor of the enrollee's
position in the Department's review of grievances submitted under subsection
(b) of Section
1368 of the Act.
(i)
STATE OF CALIFORNIA DEPARTMENT OF
MANAGED HEALTH CARE QUARTERLY REPORT OF PENDING AND UNRESOLVED GRIEVANCES
PURSUANT TO HEALTH AND SAFETY CODE SECTION
1368(c)
Name of Licensed Health Plan (as appearing on
license):
__________________________________________________
DMHC Plan File No.: _____-____________________
Report for __________Quarter 200 _____
Categories of Grievances Included in this Report: (Check
and list current enrollment)
[] Commercial
|
[] Medicare
|
[] Medi-Cal
|
[] Healthy Families
|
Under Medicare and Medi-Cal law, Medicare enrollees and
Medi-Cal enrollees each have separate avenues that are not available to other
enrollees. Therefore, grievances pending and unresolved may reflect enrollees
pursuing their Medicare or Medi-Cal appeal rights.
I. Total Number of Grievances Unresolved
Within 30 Days During the Quarter
NOTE: These include all grievances received by the plan or
any entity to which the plan has delegated grievance resolution.
|
Total |
Comm |
Medicare |
Medical |
|
|
|
|
|
A. Total number of grievances pending or submitted
over 30 days at the beginning of the quarter |
|
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C. Total number of grievances that were unresolved
within 30 days at any time during quarter (A + B) |
|
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D. Total number of grievances pending or submitted
over 30 days at the end of the quarter |
|
|
|
|
II.
Commercial Members
Number of Commercial Member Grievances Unresolved
Within 30 Days During the Quarter by Type of Grievance
Reason Why Pending Over 30
Days |
Total, all grievance
types |
Coverage
Disputes |
Disputes Involving Medical
Necessity |
Quality of
Care |
Access to Care (including
appointments) |
Quality of Service |
|
|
|
|
|
|
|
1. Pending in Plan's Internal Grievance
System |
|
|
|
|
|
|
2. Pending in Department's consumer complaint
process |
|
|
|
|
|
|
3. Pending in Department's Independent Medical Review
system |
|
|
|
|
|
|
4. Submitted to Arbitration |
|
|
|
|
|
|
5. Pending in Court |
|
|
|
|
|
|
6. Pending, other dispute resolution |
|
|
|
|
|
|
Total |
|
|
|
|
|
|
III. Medicare Members (complete if Medicare +
Choice products provided by Plan)
Number of Medicare Member Grievances Unresolved
Within 30 Days During the Quarter by Type of Grievance
Reason Why Pending Over 30
Days |
Total, all grievance
types |
Coverage
Disputes |
Disputes Involving Medical
Necessity |
Quality of
Care |
Access to Care (including
appointments) |
Quality of Service |
|
|
|
|
|
|
|
1. Pending in Plan's Internal Grievance
System |
|
|
|
|
|
|
2. Submitted to Medicare Appeals System |
|
|
|
|
|
|
3. Pending in Department's consumer complaint
process |
|
|
|
|
|
|
4. Pending in Department's Independent Medical Review
system |
|
|
|
|
|
|
5. Submitted to Arbitration |
|
|
|
|
|
|
6. Pending in Court |
|
|
|
|
|
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7. Pending other dispute resolution |
|
|
|
|
|
|
Total |
|
|
|
|
|
|
IV.
Medi-Cal Members (Complete if Medi-Cal Managed Care products offered by Plan)
Number of Medi-Cal Member Grievances Unresolved
Within 30 Days During the Quarter by Type of Grievance
Reason Why Pending Over 30
Days |
Total, all grievance
types |
Coverage
Disputes |
Disputes Involving Medical
Necessity |
Quality of
Care |
Access to Care (including
appointments) |
Quality of Service |
|
|
|
|
|
|
|
1. Pending in Plan's Internal Grievance
System |
|
|
|
|
|
|
2. Submitted to Medi-Cal fair hearing
process |
|
|
|
|
|
|
3. Pending in Department's consumer complaint
process |
|
|
|
|
|
|
4. Pending in Department's Independent Medical Review
system |
|
|
|
|
|
|
5. Submitted to Arbitration |
|
|
|
|
|
|
6. Pending in Court |
|
|
|
|
|
|
7. Pending, other dispute resolution |
|
|
|
|
|
|
Total |
|
|
|
|
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VERIFICATION
I, the undersigned, have read and signed this report and
know the contents thereof, and verify that, to the best of my knowledge and
belief, the information included in this report is true.
|
BY: |
___________________________ |
|
|
(Signature of Individual
Authorized to Sign on Behalf of Plan) |
|
|
|
|
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___________________________(Typed
Name, Title, Phone) |