Cal. Code Regs. Tit. 22, § 53858 - Member Grievance Procedures
(a)
Each plan in a designated region shall establish and maintain written
procedures for the submittal, processing, and resolution of all member
grievances and complaints. The grievance system shall include the handling of
complaints and shall:
(1) Operate according
to the written procedures, which shall be approved in writing by the department
prior to use. Amendments shall be approved in writing by the department prior
to implementation of the revised procedure.
(2) Be described in information sent to each
member within 7 days of the date of enrollment in the plan and annually
thereafter, pursuant to sections
53893 and
53894. The description shall
include:
(A) An explanation of the plan's
system for processing and resolving grievances, and how a member is to use
it.
(B) A statement that grievance
forms are available in the office of each primary care provider, or in each
member services department of the plan, in the case of a plan in which all
primary care providers are the exclusive providers of that plan and are
contiguously located.
(C) A
statement that grievances may be filed in writing or verbally directly with the
plan in which the member is enrolled or at any office of the plan's
providers.
(D) The local or
toll-free telephone number a member may call to obtain information, request
grievance forms, and register a verbal grievance.
(E) A written statement explaining the
member's right to request a fair hearing, provided pursuant to sections
50951,
51014.1,
51014.2, and
53894.
(F) An explanation of the state's Medi-Cal
Managed Care Ombudsman program and the program's voice and TDD telephone
numbers.
(b)
Each plan shall make local or toll-free telephone service available to members
during normal business hours for requesting grievance forms, filing verbal
grievances, and requesting information.
(c) Each plan shall provide upon request a
grievance form, either directly or by mail if mailing is requested to any
member requesting the form.
(d)
Each plan shall provide assistance to any member requesting assistance in
completing the grievance form.
(e)
The member grievance procedures shall at a minimum provide for:
(1) The recording in a grievance log of each
grievance received by the plan, either verbally or in writing. The grievance
log shall include the following information:
(A) The date and time the grievance is filed
with the plan or provider.
(B) The
name of the member filing the grievance.
(C) The name of the plan provider or staff
person receiving the grievance.
(D)
A description of the complaint or problem.
(E) A description of the action taken by the
plan or provider to investigate and resolve the grievance.
(F) The proposed resolution by the plan or
provider.
(G) The name of the plan
provider or staff person responsible for resolving the grievance.
(H) The date of notification of the member of
the proposed resolution.
(2) The immediate submittal of all medical
quality of care grievances to the medical director for action.
(3) The submittal, at least quarterly, of all
member grievances to the plan's quality assurance committee or review and
appropriate action. For purposes of this subsection, member grievances shall
include but not be limited to those related to access to care, quality of care,
and denial of services.
(4) The
review and analysis, on at least a quarterly basis, of all recorded grievances
related to access to care, quality of care and denial of services, and take
appropriate action to remedy any problems identified in such reviews.
(5) The mailing of a written notice of the
proposed resolution to the member. Each notice shall include information about
the member's right to request a fair hearing pursuant to sections
50951,
51014.1,
51014.2, and
53894.
(6) A system for addressing any cultural or
linguistic requirements related to the processing of member grievances
prescribed in the contract between the plan and the department.
(7) A procedure for the expedited review and
disposition of grievances in the event of a serious or imminent health threat
to a member, in accordance with Health and Safety Code section
1368
and
1368.02.
(f) Grievance forms shall be available in the
offices of each of the plan's primary care providers, or in each member
services department of the plan, in the case of a plan in which all primary
care providers are the exclusive providers of that plan and are contiguously
located.
(g) Each plan shall adhere
to the following requirements and time frames in processing member grievances:
(1) Member grievances shall be resolved
within thirty days of the member's submittal of a written grievance or if the
grievance is made verbally, it shall be resolved within 30 days of the written
record of the grievance.
(2) In the
event resolution is not reached within thirty days, the member shall be
notified in writing by the plan of the status of the grievance and shall be
provided with an estimated completion date of resolution.
(h) Each plan shall maintain in its files
copies of all grievances, the responses to them, and logs recording them for a
period of five years from the date the grievance was filed.
Notes
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 10950 through 10965, 14087.3, 14087.4 and 14450, Welfare and Institutions Code.
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
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