When a provider of services has a grievance or complaint
concerning the processing or payment of his claims for services provided under
the Medical Assistance Program the following procedures must be met:
(a) The provider shall initiate an appeal, by
submitting a grievance or complaint in writing, within 90 days of the action
precipitating the grievance or complaint, to the appropriate fiscal
intermediary identifying the claims involved and specifically describing the
disputed action or inaction regarding such claims.
(b) The fiscal intermediary shall acknowledge
the written grievance or complaint within 15 days of its receipt.
(c) The fiscal intermediary shall determine
whether or not the grievance or complaint shall be referred to professional
peer review.
(1) When the grievance or
complaint is not referred to professional peer review, the fiscal intermediary
shall review the merits of the grievance or complaint and send a written
decision of its conclusion and reasons therefor to the provider within 30 days
of the acknowledgment of the receipt of the grievance or complaint.
(2) When the grievance or complaint is
referred to professional peer review:
(A) All
parties concerned shall be notified that the referral has been made to
professional peer review and that a final determination will require up to 60
days from the acknowledgment of receipt of the grievance or
complaint.
(B) The professional
peer review shall make its evaluation and submit its findings and
recommendations to the fiscal intermediary and the provider within 30 days of
the referral from the fiscal intermediary.
(C) The fiscal intermediary, after taking
into consideration the findings and recommendations of the professional peer
review, shall send a written decision to the
provider.
(d)
After these procedures have been followed, a provider who is not satisfied with
the appeal decision by the fiscal intermediary, may seek appropriate judicial
remedies in compliance with Section
14104.5
of the Welfare and Institutions Code, no later than one year after receiving
notice of the decision.
Notes
Cal. Code Regs. Tit. 22, §
51015
1.
Amendment filed 1-25-79; effective thirtieth day thereafter (Register 79, No.
4). For prior history, see Registers 66, No. 30; 68, No. 43; 70, No. 30; and
74, No. 3.
2. Amendment filed 12-6-85; effective thirtieth day
thereafter (Register 85, No. 49).
3. Amendment filed 4-2-92;
operative 4-2-92 pursuant to Government Code section
11346.2(d)
(Register 92, No. 14).
4. Change without regulatory effect amending
NOTE filed 12-16-2013 pursuant to section
100, title 1, California Code of
Regulations (Register
2013,
No. 51).
Note: Authority cited: Section
20, Health and Safety Code; and
Sections
14104.5
and
14124.5,
Welfare and Institutions Code. Reference: Sections
14021,
14053,
14104.5,
14124.24
and
14131,
Welfare and Institutions Code.
1. Amendment filed
1-25-79; effective thirtieth day thereafter (Register 79, No. 4). For prior
history, see Registers 66, No. 30; 68, No. 43; 70, No. 30; and 74, No.
3.
2. Amendment filed 12-6-85; effective thirtieth day thereafter
(Register 85, No. 49).
3. Amendment filed 4-2-92; operative 4-2-92
pursuant to Government Code section
11346.2(d)
(Register 92, No. 14).
4. Change without regulatory effect amending
Note filed 12-16-2013 pursuant to section 100, title 1, California Code of
Regulations (Register 2013, No. 51).