Cal. Code Regs. Tit. 22, § 53914 - Member Grievance Procedures
(a) Each GMC plan 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 upon enrollment in the GMC plan and annually thereafter, pursuant to
Sections 53926.5 and
53927. The description shall
include:
(A) An explanation of the GMC 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 GMC plan, in the case of a GMC 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
GMC plan in which the member is enrolled or at any office of the GMC plan's
providers.
(D) The telephone number
a member may call to obtain information, request grievance forms, and register
a verbal grievance.
(E) A statement
that a member has a right to request a fair hearing, pursuant to Section
50951.
(b) Each GMC 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 GMC 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 GMC 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 GMC 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 GMC plan or provider.
(B)
The name of the member filing the grievance.
(C) The name of the GMC 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 GMC plan or provider to investigate and resolve the
grievance.
(F) The proposed
resolution by the GMC plan or provider.
(G) The name of the GMC 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 or
dental quality of care grievances to the medical or dental director for
action.
(3) The submittal, at least
quarterly, of all quality of care grievances to the GMC plan's quality
assurance committee for review and appropriate action.
(4) 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 Section
50951.
(f) Grievance forms and a grievance log shall
be available in the offices of each of the GMC plan's primary care providers,
or in each member services department of the GMC plan, in the case of a GMC
plan in which all primary care providers are the exclusive providers of that
plan and are contiguously located.
(g) Each GMC 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 filing the grievance.
(2) In the event resolution is not reached
within thirty days, the member shall be notified in writing by the GMC plan of
the status of the grievance and shall be provided with an estimated completion
date of resolution.
(h)
Each GMC plan shall maintain in its files copies of all grievances, the
responses to them, and logs recording them for a period fo five years from the
date the grievance was filed.
Notes
Note: Authority cited: Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Sections 10950 through 10965, 14089, 14089.2 and 14450, Welfare and Institutions Code.
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